First Name: *

Last Name: *

Email: *

Job Title: *

Name of Company/Organization: *

How did you hear about this event?: * Nutrition Connections email OPHA website Nutrition Connections website Colleague Other

What sector do you work in?: * Academic/Research Community Health Hospital Public Health Government Not for Profit Primary Health/Family Health Team Industry Private Practice Child Care Primary or Secondary Education Recreation Student/Intern Other

Which type of position best describes your work?: * Program staff/Direct service provider Manager Senior administrator Support/Administrative staff Board member Other

What region does your organization serve?: * Northern Ontario Eastern Ontario Central Ontario Southwest Ontario Province-wide Nation-wide Other

Do you have any questions?: *

Is there a topic you would like Nutrition Connections to provide a course on in the future?: *