Child Nutrition Institute

STEP 1 of 5 - Participant Information - Instructions

Note: Please ensure ALL areas are filled out completely.

Participant Information
First Name:
MI:	(Enter "0" if inapplicable or unknown.)
Last Name:
Mailing Address:
City:		State:	Zip:	+4:
Phone:
Do you have an e-mail address?
	Yes No
E-mail Address:
Re-type Email Address:
Name you would like on your name tag:
Name you would like to appear on your certificate:
Work Information
Supervisor’s Name:
Local Agency	(School District/Child Care Center)
CACFP or NSLP:	Child & Adult Care Food Program National School Lunch Program Other - Please specify name:
Supervisor’s Work Address:
Supervisor’s City:		State:	Zip:	+4:
Supervisor’s Work Phone:
Does your supervisor have an e-mail address?
	Yes No
Supervisor’s E-mail Address:
Re-type E-mail Address: