Food As Medicine Registration Form


Name:

Address:

Phone:

Email:


Which class(es) are you signing up for? (Please list title and date.)


________________________________________________________________ Cost: ________


________________________________________________________________ Cost: ________


________________________________________________________________ Cost: ________


________________________________________________________________ Cost: ________


________________________________________________________________ Cost: ________


Total payment: $ _______


Send check made payable to Sharon A. Kane, 18 Cedar Hill Road, Ashland MA, 01721


Briefly describe your current diet and health situation: