JANICE KAY'S GREEN CUISINE
                  REGISTRATION FORM


NAME:


ADDRESS:

 
CITY/STATE/ZIP CODE:


TELEPHONE NUMBER:

EMAIL-ADDRESS:


What are your favorite foods?





What are your least favorite foods?





Do you have any food allergies: if so, please describe.





What is your ethnic food heritage?





What would you most like to learn from this class? 





How did you learn about this program?
 
 Friend     Publicity    Physician       Fitness Center      Other


Thank you for providing this information.  

Please return this form with fee to:
     Janice Kay
     1104 Prospect Avenue
     Bethlehem, PA. 18018