My City Kitchen, Inc.
384 Pratt Street / P.O. Box 176
Meriden, CT 06450
Phone: (203) 630-2870 / (fax): 203-630-2873
E-mail: [email protected]
Website: facebook: My City Kitchen, Inc
Name: _______________________________________
Full Address: _________________________________________________________
Contact Number: _______________________
Email: ____________________________________
ANY KNOWN FOOD ALLERGIES: _________________________________________
One Time Class: YES / NO
4 Week Session: YES / NO
If it’s one session (Name of the Class): _______________________________
What are you interested in cooking? ______________________________________
Are you a SNAP ED OR WIC Recipient?:
Yes or NO
□ I agree to participate in this voluntary survey □ I decline to participate in this voluntary survey
Ethnicity: □ American Indian □ Asian □ Black □ Caucasian □ Hispanic □ Other ___________________
Members of Household: □ Adults:__________ □ Children: ____________
Head of Household: □ Married □ Single □ Single Female Head of Household □ Single Male Head of
household □ Grandparent / Relative or Guardian
Estimated Annual Gross Income: □ Equal to or less than $20,000
□ $20,001 to $35,000
□ $35,001 to $50,000
□ Greater than $50,000
I hereby consent to participate in My City Kitchen, Inc. cooking program. I hereby agree and acknowledge that
the program may include, among others any one or more of the following activities: preparing food and recipes;
learning basic cooking techniques; nutrition lessons; and a field trip to a local farm, farmers market or grocery
store. While such activities will be conducted under the supervision of a professional chef, such activities may
involve the use of a microwave and other potentially dangerous items.
I hereby give My City Kitchen, Inc. permission to use my name, voice, likeness and biographical material in
connection solely for promotion of its products and services, for both broadcast and non-broadcast purposes.
I hereby release My City Kitchen, Inc. and there respective affiliates from any and all liability, loss, damage,
cost of expense of any nature whatsoever, as a result of participation in the program.
I hereby authorize the administering of BASIC first aid procedures as may be deemed necessary. In case of a
major accident, injury or illness requiring immediate medical attention, I authorize My City Kitchen, Inc. or
such other individuals conducting the class, to act on my behalf provided that they make diligent efforts as the
nature of the emergency permits to notify me at the phone number indicated above.