PEC Presents :The Pathways Plate Program

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Complete this form to register for the Pathways Plate Program, a free 10 month course for families (adults & children) that focuses on health education, nutrition and more. Please complete this form for each person interested in participating in the program.

Email *

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Date Of Birth *

YYYY

Gender *

Male

Female

Prefer not to say

Ethnicity *

African American

Asian

Native American

Hispanic

Bi-Racial

White

Other:

Required

How would you like to be contacted? *

Text Message

Phone Call

Snail Mail

What are 2 of your personal health goals? *

A copy of your responses will be emailed to the address you provided.

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