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Program Registration
Please complete the following questions to register for a Meals on Wheels Health & Wellness program.
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* Indicates required question
Please select which program(s) you would like to register for:
*
City Stops - Southern Grace
Brains in Bloom - May
Bincocize / May 14 - July 19
Caregiver Writing Experience, May 7
Painting at the Carnegie Center
Cooking Class with LaSoupe, May 15
Holocaust & Humanity Center
Required
Your Name (First and Last).
Please include any additional guests that you plan to bring here, as well.
*
Your answer
Phone
*
Your answer
Email
Your answer
Do you prefer to be contacted via phone or email?
*
Email
Phone
Do you have transportation to and from the program?
*
Yes
No
Other:
Emergency Contact (include name and phone number)
*
Your answer
Is there anything else you would like for us to know?
Your answer
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