Nutrition Essentials Applications

Prefix (Mr, Mrs, Dr, etc):*

First name:*

Last name:*

Cellphone number:*

Email address:*

In which city do you live?*

Date of Birth*

Sex*

Ethnicity*

Are you a cancer survivor?

Any diseases or conditions we should be aware of?

Where did you learn about this class series? (If you were referred by someone please mention their name)*

What is your occupation or profession?*

Are you a healthcare practitioner?*

Are you a proponent or supporter of a specific diet currently? Or are you adhering currently to a specific diet? e.g. paleo, banting, keto, carnivore, vegetarian, vegan or gluten free?*

What is your intention for attending the class?*

What is your expectation regarding the class series?*

The Food for Life program was
designed by Physicians Committee for Responsible Medicine (PCRM), a 501(c)(3) nonprofit that works
to promote disease prevention and survival through nutrition. This class will help you better understand
the connection between healthful nutrition and disease prevention, while teaching you how to prepare a
number of delicious and nutritious meals.

The nutrition information presented in the Food for Life classes and the accompanying videos were
developed and reviewed by registered dietitians and a medical doctor. However, the information
presented in the classes and through the materials is not intended to be a substitute for professional
medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified
health professional with any questions you may have regarding a medical condition.

I understand that the information
presented in the Food for Life cooking class program is not intended to replace the advice of my medical doctor or
other health care professional with whom I consult. My cooking instructor has advised me of his/her credentials and
training in teaching this class. I understand that food prepared during this cooking class series may contain common
allergens, and I hereby assume any risk(s) of personal injury or illness that may result from consuming or handling
this food. In consideration of participating in Food for Life classes, I acknowledge and understand the dangers and
risks inherent in such activities related to preparing food, consuming certain foods, and working with tools and
appliances. I hereby waive, release, and discharge Physicians Committee, Food for Life and its instructors, officers,
employees, and volunteers against any and all claims, demands, action, or causes of action for costs, expenses, or
damages to personal property or personal injury, or death, which may result from my participation or child’s
participation in these activities. I assume full responsibility for any injuries or damages resulting from my participation
or child’s participation in this program including responsibility for using reasonable judgment in all phases of
participation of the program. I acknowledge that my participation or child’s participation is solely at my own risk, and
that I assume full responsibility for any resulting injuries and damages. I understand that it is my responsibility to
notify the event host(s) and instructor of any emergency medical information and ANY food allergies/or dietary
restrictions for me or my child. I also hereby give PCRM the absolute right and permission, with respect to any film,
photography, video or audio recordings being made of me and with respect to my participation in this class: a) To
copyright, use, re-use, publish, and re-publish the same in whole or in part, in any medium; and b) To use my name
in conjunction therewith, if so desired. I release and discharge PCRM and its contractors and agents, such as
producers and film makers, from any and all liabilities, claims or demands arising out of or in connection with the use
of these film, photographs, video or audio recordings. This authorization and release shall also run to the benefit of
the employees, officers, directors, agents, legal representatives, licensees, and assigns of PCRM. I understand that I
will receive no compensation, monetary or otherwise, in exchange for this agreement or for the use of these
photographs, film, video or audio recordings.

I understand that the information
presented in the Food for Life cooking class program is not intended to replace the advice of my medical doctor or
other health care professional with whom I consult. My cooking instructor has advised me of his/her credentials and
training in teaching this class. I understand that food prepared during this cooking class series may contain common
allergens, and I hereby assume any risk(s) of personal injury or illness that may result from consuming or handling
this food. In consideration of participating in Food for Life classes, I acknowledge and understand the dangers and
risks inherent in such activities related to preparing food, consuming certain foods, and working with tools and
appliances. I hereby waive, release, and discharge Physicians Committee, Food for Life and its instructors, officers,
employees, and volunteers against any and all claims, demands, action, or causes of action for costs, expenses, or
damages to personal property or personal injury, or death, which may result from my participation or child’s
participation in these activities. I assume full responsibility for any injuries or damages resulting from my participation
or child’s participation in this program including responsibility for using reasonable judgment in all phases of
participation of the program. I acknowledge that my participation or child’s participation is solely at my own risk, and
that I assume full responsibility for any resulting injuries and damages. I understand that it is my responsibility to
notify the event host(s) and instructor of any emergency medical information and ANY food allergies/or dietary
restrictions for me or my child. I also hereby give PCRM the absolute right and permission, with respect to any film,
photography, video or audio recordings being made of me and with respect to my participation in this class: a) To
copyright, use, re-use, publish, and re-publish the same in whole or in part, in any medium; and b) To use my name
in conjunction therewith, if so desired. I release and discharge PCRM and its contractors and agents, such as
producers and film makers, from any and all liabilities, claims or demands arising out of or in connection with the use
of these film, photographs, video or audio recordings. This authorization and release shall also run to the benefit of
the employees, officers, directors, agents, legal representatives, licensees, and assigns of PCRM. I understand that I
will receive no compensation, monetary or otherwise, in exchange for this agreement or for the use of these
photographs, film, video or audio recordings.

I have read the disclaimer*

Our Requirements:

A commitment and dedication to attend the 4 class series.

Willingness to put into practice the concepts conveyed in this class series determine if it could work for you, hold considerable health benefits and produce results.

A teachable spirit open to new knowledge and information never considered before.

A commitment and motivation to improve their way of life in a sustainable natural way.

A willingness to learn self-control or good healthy habits.

Open to considering being part of a support group to work on possible emotional or mental blocks when it comes to eating.

Willing to put into practice what is learned for the specified time period in order to get the desired results.

Nutrition Essential Classes

Our Requirements: