Registration Form
BINUS Nutrition Program
Name
*
Binusian ID
*
example: BN001234567
Phone Number (WA)
*
Email (@binus.edu)
*
example: tony.stark@binus.edu
Weight (kg)
*
Height (cm)
*
Gender
*
Male
Female
Work Location
*
Please Select
Apple Office Park 9
BC Syahdan
Binus ASO
Binus Square
BULC Palembang
BULC Pontianak
BULC Semarang
Kampus Alam Sutera
Kampus Anggrek
Kampus Bandung
Kampus Bekasi
Kampus FX
Kampus JWC
Kampus Kijang
Kampus Malang
Kampus Syahdan
RISE BX
School Bekasi
School Serpong
School Simprug
Consultation Goals
*
Apply a pattern for healthy life
Composition of diet and obesity
Healthy Ways to Gain Weight
Family Nutrition Guide
Consultation Goals
*
Apply a pattern for healthy life
Family Nutrition Guide
Are you married?
*
Yes
No
Are you pregnant or breastfeeding mother?
*
Yes
No
Consultation via
*
Zoom
Ms. Teams
Appointment
*
Disclaimer
*
I am voluntarily and consciously willing to take part in nutrition consultation program organized by BINUS and MUFIT Indonesia called BINUS Nutrition Program. I am willing to be contacted by MUFIT’s nutritionists and provide health information related to my health problems or fitness goals that I want to achieve during the program. The health data that I provide will fully be BINUS’ which will then be used for employee health purposes and will be kept confidential from the public. If in the implementation of this nutritionist program there are problems, I am willing to solve them by deliberation and kinship. In agreeing to this, I have no coercion from any party, so I am willing to follow this consultation process from start to finish.
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