Intro Baseline Survey

Your Name/Nom (required)


Your Age Range/Âge(required)

<1818-2425-3435-4445-5455-64

Gender/Sexe

Female/FémininMale/MasculinOther (e.g., transgender or transfluid)/Autre (p.ex. transgenre)

Where do you live? / Où habitez-vous?

City of Cornwall / Ville de CornwallDundasGlengarryPrescottRussellStormontOther/Autre

Other:

How often do you usually choose (buy, pick, or catch) local food from the following sources?À quelle fréquence est-ce que vous choisissez (achetez, ceuillez ou attrapez) des aliments locaux provenant des sources suivantes? (required)

• Community Supported Agriculture (CSA) / Agriculture soutenue par la communauté (ASC):
• Farmgate / À la Ferme:
• Farmer's market / Marché des producteurs:
• Garden / Jardin:
• Grocery store / Supermarché ou épicerie:
• Local food event / Événement d'aliments locaux:
• Pick-your-own / auto-cueillette:
• Restaurant:
• Other:

How did you hear about the Local Food Challenge?Comment avez-vous pris connaissance du Défi des aliments locaux?

FacebookTwitterWebsite / Site internet.Poster, sign, or flyer / Affiche ou dépliantNewspaper / JournalLocal Food Partner (e.g., local food business or program) / Partenaire d'aliments locaux (ex: Entreprise ou programme d'aliments locaux)Community event or program / Événement ou programme communautaire.EOHU Workplace Health Promotion Program e-newsletter/Infolettre du programme de promotion de la santé en milieu de travailRadioTV CogecoOther / Autre

Please specify which website or program/ SVP préciser :

Consent

I consent to receiving email communication from the Local Food Challenge (LFC) administrator about LFC activities and updates. I understand that my name and e-mail address will be used for my participation in the LFC prize draw. My name and e-mail address will not be shared publicly without further consent. Your name, gender, age category, and e-mail will not appear in any report or other material resulting from the LFC. The information collected will be reported in group format to help the LFC partner committee improve the 2017 LFC. If you have any questions about the LFC or the information collected in this registration form, please contact Lynne Giroux, Health Promotion Specialist at the Eastern Ontario Health Unit, at 613-933-1375 extension 231.

Thank You / Merci!