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: firstname.lastname@example.org 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.