Nutrition & Dietetics Interest Form


Nutrition & Dietetics

Nutrition & Dietetics

Student Interest Form

First Name

Last Name

Address

City

State

Zip

E-Mail

Phone

Cell Phone

I am interested in being contacted with information on classes and workshops related to this program.

I have reviewed the Dietetic Technology Consortium Program Curriculum at http://www.pvc.maricopa.edu/%7Enutrition/consort.html and I plan on completing the full certificate program.

I am considering completing the Dietetic Technology Consortium Program at PVCC.

I am interested in taking approximately classes per term.

I am interested in taking summer courses.

I am willing to take a class at another MCCCD college if a class is not available at a time that meets my needs (classes are offered at CGCC, SCC, GCC, and MCC).

My schedule allows me to take: (please enter the number of classes)

day classes

evening classes

weekend classes

on-line classes

I am interested in courses offered in:

distance learning format (on-line or flex)

traditional classroom format (face-to-face)

I would like to transfer into a 4-year degree program and pursue the Registered Dietitician (R.D.) credential.

10.

Please check other certifications that you would be interested in:

Dietary Managerial Certification

ACSM Health and Fitness Instructor Certification (American College of Sports Medicine)

ACSM Personal Trainer Certification

NASM Personal Trainer Certification (National Academy of Sports Medicine)

NSCA Personal Trainer Certification (National Strength and Conditioning Association)

ACE Personal Trainer Certification (American Council on Exercise)

ACE Group Fitness Instructor Certification

Food Service (e.g. School Nutrition Association (SNA) Certification)

Other Allied Health degree / certifications: (please specify)

Other:

10.

I would be interested in taking additional courses to help me specialize in:

Nutrition for Seniors (60+)	Sports Nutrition	Diabetes
Obesity / Weight Management	Lifestyle Coaching	Operating my own business

Other:

11.

What past professional or personal experience do you have in the field of health and fitness that has contributed to your interest in this program?

What is your Education Background:

High School Diploma	College AA/AAS Degree:
College BS/BA Degree:	College MS/MA Degree:

Other Degrees or Certifications:

Click here to submit this form.

For more information, contact Lori Anonsen MS, RD, 602-787-7295
or lori.anonsen@pvmail.maricopa.edu

Last updated: June 10, 2007
Paradise Valley Community College- URL-http://www.pvc.maricopa.edu/fitness/Nutrition_IntrestForm.htm
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