Cook Chill Chat Registration

About you

The following registration form will ask for your contact details, dietary requirements and demographics (e.g. date of birth, gender, postcode).

We will only use your contact details to contact you about the program (e.g. details for the Zoom classes, change in workshop times or cancellations). We intend to use your responses to the demographic questions for reporting and evaluation purposes only, where you will remain anonymous.

By completing this form you give consent to Healthy Cities Illawarra to collect and store information about yourself and use the collected information for reporting and evaluation.

To say thank-you, we will provide you with a copy of our Cook Chill Chat Cookbook. If you would like to receive a copy, please leave your mailing address in question 10.

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* 1. Please complete the following:

First and last name

Suburb

State

Postal Code

Country

Email Address

Phone Number

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* 2. What is your date of birth?

Date of birth

Date

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* 3. What is your gender?

Male

Female

Other (please specify)

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* 4. Are you of Aboriginal or Torres Strait Islander origin?

Aboriginal

Torres Strait Islander

Aboriginal and Torres Strait Islander

I prefer not to say

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* 5. What is your country of birth?

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* 6. What language do you speak at home?

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* 7. Do you have a disability or impairment?

Yes, I may need assistance with:

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* 8. Do you have any dietary requirements (e.g. vegetarian) or food allergies? If so, what are they?

Yes (please specify)

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* 9. What are you hoping to get out of the program? (Tick as many responses as you like)

Learn new recipes

Improve my cooking skills

Increase my confidence in the kitchen

Learn how to eat healthily on a budget

Keep connected with an online community

Other (please specify)

Cook Chill Chat Registration

About you

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* 1. Please complete the following:

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* 2. What is your date of birth?

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* 3. What is your gender?

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* 4. Are you of Aboriginal or Torres Strait Islander origin?

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* 5. What is your country of birth?

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* 6. What language do you speak at home?

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* 7. Do you have a disability or impairment?

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* 8. Do you have any dietary requirements (e.g. vegetarian) or food allergies? If so, what are they?

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* 9. What are you hoping to get out of the program? (Tick as many responses as you like)

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* 10. If you would like to receive a copy of our Cook Chill Chat Cookbook, please leave your mailing address below.