Online Registration Form

Address:
Nutrition and Diet Services
3 York Castle Avenue
Liguanea, Kingston 6
Tel: 876 322 3142
Tel: 876 977 4561
Fax: 876 702 4058
Mobile: 876 322 3142
Email: nutritionjamaica@hotmail.com
Website: www.jamaicanutrition.com

FUNCTIONAL NUTRITION COURSE
COURSE APPLICATION FORM
(Please complete both pages)

NAME: GENDER:  Male Female
TELEPHONE: EMAIL:
ADDRESS/PLACE OF WORK:
DISCIPLINE OR FIELD OF PRACTICE:
QUALIFICATION: (HIGHEST LEVEL)
Outline prior exposure in foods and/or nutrition or in programmes or services that involve nutrition:
1. Training:
2. Exposure:
Are you or do you wish to become a financial member of JINN?  Yes No

LEVEL 2
REGISTRATION


FUNCTIONAL NUTRITION

For nutrition providers (persons credentialed at level 1), persons involved in fitness services, and food/products/supplements provision and who meet the qualifications criteria wishing to be certified as nutrition advocates or for persons who are exempt from the Level 1 course.

Select your special interest areas specifying (on line) your first and second choice.  Exercise/Sports and Fitness Nutrition Wellness Foods and Nutrition Planning (with emphasis on institutional feeding at schools, workplaces, food establishments) Wellness and Healthy Lifestyle Nutrition
Please select your first preference:  Exercise/Sports and Fitness Nutrition Wellness Foods and Nutrition Planning (with emphasis on institutional feeding at schools, workplaces, food establishments) Wellness and Healthy Lifestyle Nutrition
How do you plan to use the training received?
Will you be completing the 1 month credential experience following certification?  Yes No
 
FEES – Indicate all that apply and total
FULL COURSE LEADING TO
CERTIFICATION – LEVEL 1
 Yes J$22,500 (per person)
CREDENTIALING – LEVEL 1 TITLES
(renewable annually)
 Yes J$ 5,000 (per person)
MEMBERSHIP IN JINN (renewable annually)  Yes J$ 2,500 (per person)
TOTAL $
TRANSACTION NUMBER:
DOWN PAYMENT: $ BALANCE OUTSTANDING: $
DATE: SIGNATURE:

Bank Options: Sagicor Bank,
NCB, BNS. Please call for relevant account number.
Include the transfer number on this form to indicate verification of payment.