Healthy Dozen Club Registration Form
Name and Address of organization:___________________________________
Contact person: ___________________ Title:______________________________
Phone:________________ Fax: ____________ Email: ___________________
Description of your organization: ______________________________________________
Include the following details:
Activities- _____________________________________________________________
Educational ____________________________________________________________
Lifestyle/Physical activity ___________________________________________________
Community Activity _______________________________________________________
Objectives:________________________________________________________________
_______________________________________________________________________
Target audience (provide detail such as age, sex,):______________________________________
Summary of the program (if applicable):____________________________________________
_______________________________________________________________________
_______________________________________________________________________
Program timeline: ___________________________________________________________
Please return completed form to Healthy Lifestyle Secretariat
Royal Victoria Gardens, Ministry of Health
Phone: (242) 328-1535 Fax: (242) 328-1211
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