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MOVE ACADEMIA
635 Middle Country Road, Coram, NY 11727 • (631) 846-1509 • dbatista1992@gmail.com
COOKING CLASS — STUDENT INTAKE
Help us plan meals you'll love — this takes about 3 minutes

Welcome to cooking class! This quick form tells us what you like to eat so we can plan recipes everyone enjoys. It's not a waiver or a contract — just your food profile. A parent or guardian is welcome to fill it out for a student.

That's It!

The information below is accurate, and I'll let Move Academia know if anything changes — especially allergies.

Today's Date: September 9, 2026


First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
Information
Completing this form:
I am the student
Parent / guardian, on behalf of the student

2.  Allergies & Food Rules

Does the student have ANY food allergies or intolerances? *
No
Yes

Please list ALL allergies and intolerances in detail (write NONE if none):

Any foods avoided for religious, cultural, or dietary reasons (halal, kosher, vegetarian, etc.)?

3.  Vegetables

Which vegetables does the student LIKE? (check all that apply)
Broccoli
Carrots
Bell peppers
Tomatoes
Cucumbers
Lettuce / greens
Spinach
Corn
Green beans
Peas
Potatoes
Sweet potatoes
Onions
Mushrooms
Zucchini / squash
Cauliflower
Other vegetables the student loves:
Vegetables the student strongly dislikes or won't eat:

4.  Proteins

Which proteins does the student LIKE? (check all that apply)
Chicken
Beef
Turkey
Pork
Fish
Shrimp / seafood
Eggs
Cheese / dairy
Beans / lentils
Tofu
Deli meats
Peanut butter / nuts
Other proteins the student loves:
Proteins the student strongly dislikes or won't eat:

5.  Anything Else?  (optional)


Anything else that would make class great — favorite meals, textures or smells to avoid, support needs, or a dish you'd love to learn to cook:
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Completing this form:
I am the student
Parent / guardian, on behalf of the student

2.  Allergies & Food Rules

Does the student have ANY food allergies or intolerances? *
No
Yes

Please list ALL allergies and intolerances in detail (write NONE if none):

Any foods avoided for religious, cultural, or dietary reasons (halal, kosher, vegetarian, etc.)?

3.  Vegetables

Which vegetables does the student LIKE? (check all that apply)
Broccoli
Carrots
Bell peppers
Tomatoes
Cucumbers
Lettuce / greens
Spinach
Corn
Green beans
Peas
Potatoes
Sweet potatoes
Onions
Mushrooms
Zucchini / squash
Cauliflower
Other vegetables the student loves:
Vegetables the student strongly dislikes or won't eat:

4.  Proteins

Which proteins does the student LIKE? (check all that apply)
Chicken
Beef
Turkey
Pork
Fish
Shrimp / seafood
Eggs
Cheese / dairy
Beans / lentils
Tofu
Deli meats
Peanut butter / nuts
Other proteins the student loves:
Proteins the student strongly dislikes or won't eat:

5.  Anything Else?  (optional)


Anything else that would make class great — favorite meals, textures or smells to avoid, support needs, or a dish you'd love to learn to cook:
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Completing this form:
I am the student
Parent / guardian, on behalf of the student

2.  Allergies & Food Rules

Does the student have ANY food allergies or intolerances? *
No
Yes

Please list ALL allergies and intolerances in detail (write NONE if none):

Any foods avoided for religious, cultural, or dietary reasons (halal, kosher, vegetarian, etc.)?

3.  Vegetables

Which vegetables does the student LIKE? (check all that apply)
Broccoli
Carrots
Bell peppers
Tomatoes
Cucumbers
Lettuce / greens
Spinach
Corn
Green beans
Peas
Potatoes
Sweet potatoes
Onions
Mushrooms
Zucchini / squash
Cauliflower
Other vegetables the student loves:
Vegetables the student strongly dislikes or won't eat:

4.  Proteins

Which proteins does the student LIKE? (check all that apply)
Chicken
Beef
Turkey
Pork
Fish
Shrimp / seafood
Eggs
Cheese / dairy
Beans / lentils
Tofu
Deli meats
Peanut butter / nuts
Other proteins the student loves:
Proteins the student strongly dislikes or won't eat:

5.  Anything Else?  (optional)


Anything else that would make class great — favorite meals, textures or smells to avoid, support needs, or a dish you'd love to learn to cook:
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Completing this form:
I am the student
Parent / guardian, on behalf of the student

2.  Allergies & Food Rules

Does the student have ANY food allergies or intolerances? *
No
Yes

Please list ALL allergies and intolerances in detail (write NONE if none):

Any foods avoided for religious, cultural, or dietary reasons (halal, kosher, vegetarian, etc.)?

3.  Vegetables

Which vegetables does the student LIKE? (check all that apply)
Broccoli
Carrots
Bell peppers
Tomatoes
Cucumbers
Lettuce / greens
Spinach
Corn
Green beans
Peas
Potatoes
Sweet potatoes
Onions
Mushrooms
Zucchini / squash
Cauliflower
Other vegetables the student loves:
Vegetables the student strongly dislikes or won't eat:

4.  Proteins

Which proteins does the student LIKE? (check all that apply)
Chicken
Beef
Turkey
Pork
Fish
Shrimp / seafood
Eggs
Cheese / dairy
Beans / lentils
Tofu
Deli meats
Peanut butter / nuts
Other proteins the student loves:
Proteins the student strongly dislikes or won't eat:

5.  Anything Else?  (optional)


Anything else that would make class great — favorite meals, textures or smells to avoid, support needs, or a dish you'd love to learn to cook:
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Completing this form:
I am the student
Parent / guardian, on behalf of the student

2.  Allergies & Food Rules

Does the student have ANY food allergies or intolerances? *
No
Yes

Please list ALL allergies and intolerances in detail (write NONE if none):

Any foods avoided for religious, cultural, or dietary reasons (halal, kosher, vegetarian, etc.)?

3.  Vegetables

Which vegetables does the student LIKE? (check all that apply)
Broccoli
Carrots
Bell peppers
Tomatoes
Cucumbers
Lettuce / greens
Spinach
Corn
Green beans
Peas
Potatoes
Sweet potatoes
Onions
Mushrooms
Zucchini / squash
Cauliflower
Other vegetables the student loves:
Vegetables the student strongly dislikes or won't eat:

4.  Proteins

Which proteins does the student LIKE? (check all that apply)
Chicken
Beef
Turkey
Pork
Fish
Shrimp / seafood
Eggs
Cheese / dairy
Beans / lentils
Tofu
Deli meats
Peanut butter / nuts
Other proteins the student loves:
Proteins the student strongly dislikes or won't eat:

5.  Anything Else?  (optional)


Anything else that would make class great — favorite meals, textures or smells to avoid, support needs, or a dish you'd love to learn to cook:
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Completing this form:
I am the student
Parent / guardian, on behalf of the student

2.  Allergies & Food Rules

Does the student have ANY food allergies or intolerances? *
No
Yes

Please list ALL allergies and intolerances in detail (write NONE if none):

Any foods avoided for religious, cultural, or dietary reasons (halal, kosher, vegetarian, etc.)?

3.  Vegetables

Which vegetables does the student LIKE? (check all that apply)
Broccoli
Carrots
Bell peppers
Tomatoes
Cucumbers
Lettuce / greens
Spinach
Corn
Green beans
Peas
Potatoes
Sweet potatoes
Onions
Mushrooms
Zucchini / squash
Cauliflower
Other vegetables the student loves:
Vegetables the student strongly dislikes or won't eat:

4.  Proteins

Which proteins does the student LIKE? (check all that apply)
Chicken
Beef
Turkey
Pork
Fish
Shrimp / seafood
Eggs
Cheese / dairy
Beans / lentils
Tofu
Deli meats
Peanut butter / nuts
Other proteins the student loves:
Proteins the student strongly dislikes or won't eat:

5.  Anything Else?  (optional)


Anything else that would make class great — favorite meals, textures or smells to avoid, support needs, or a dish you'd love to learn to cook:
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Completing this form:
I am the student
Parent / guardian, on behalf of the student

2.  Allergies & Food Rules

Does the student have ANY food allergies or intolerances? *
No
Yes

Please list ALL allergies and intolerances in detail (write NONE if none):

Any foods avoided for religious, cultural, or dietary reasons (halal, kosher, vegetarian, etc.)?

3.  Vegetables

Which vegetables does the student LIKE? (check all that apply)
Broccoli
Carrots
Bell peppers
Tomatoes
Cucumbers
Lettuce / greens
Spinach
Corn
Green beans
Peas
Potatoes
Sweet potatoes
Onions
Mushrooms
Zucchini / squash
Cauliflower
Other vegetables the student loves:
Vegetables the student strongly dislikes or won't eat:

4.  Proteins

Which proteins does the student LIKE? (check all that apply)
Chicken
Beef
Turkey
Pork
Fish
Shrimp / seafood
Eggs
Cheese / dairy
Beans / lentils
Tofu
Deli meats
Peanut butter / nuts
Other proteins the student loves:
Proteins the student strongly dislikes or won't eat:

5.  Anything Else?  (optional)


Anything else that would make class great — favorite meals, textures or smells to avoid, support needs, or a dish you'd love to learn to cook:
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Completing this form:
I am the student
Parent / guardian, on behalf of the student

2.  Allergies & Food Rules

Does the student have ANY food allergies or intolerances? *
No
Yes

Please list ALL allergies and intolerances in detail (write NONE if none):

Any foods avoided for religious, cultural, or dietary reasons (halal, kosher, vegetarian, etc.)?

3.  Vegetables

Which vegetables does the student LIKE? (check all that apply)
Broccoli
Carrots
Bell peppers
Tomatoes
Cucumbers
Lettuce / greens
Spinach
Corn
Green beans
Peas
Potatoes
Sweet potatoes
Onions
Mushrooms
Zucchini / squash
Cauliflower
Other vegetables the student loves:
Vegetables the student strongly dislikes or won't eat:

4.  Proteins

Which proteins does the student LIKE? (check all that apply)
Chicken
Beef
Turkey
Pork
Fish
Shrimp / seafood
Eggs
Cheese / dairy
Beans / lentils
Tofu
Deli meats
Peanut butter / nuts
Other proteins the student loves:
Proteins the student strongly dislikes or won't eat:

5.  Anything Else?  (optional)


Anything else that would make class great — favorite meals, textures or smells to avoid, support needs, or a dish you'd love to learn to cook:
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Completing this form:
I am the student
Parent / guardian, on behalf of the student

2.  Allergies & Food Rules

Does the student have ANY food allergies or intolerances? *
No
Yes

Please list ALL allergies and intolerances in detail (write NONE if none):

Any foods avoided for religious, cultural, or dietary reasons (halal, kosher, vegetarian, etc.)?

3.  Vegetables

Which vegetables does the student LIKE? (check all that apply)
Broccoli
Carrots
Bell peppers
Tomatoes
Cucumbers
Lettuce / greens
Spinach
Corn
Green beans
Peas
Potatoes
Sweet potatoes
Onions
Mushrooms
Zucchini / squash
Cauliflower
Other vegetables the student loves:
Vegetables the student strongly dislikes or won't eat:

4.  Proteins

Which proteins does the student LIKE? (check all that apply)
Chicken
Beef
Turkey
Pork
Fish
Shrimp / seafood
Eggs
Cheese / dairy
Beans / lentils
Tofu
Deli meats
Peanut butter / nuts
Other proteins the student loves:
Proteins the student strongly dislikes or won't eat:

5.  Anything Else?  (optional)


Anything else that would make class great — favorite meals, textures or smells to avoid, support needs, or a dish you'd love to learn to cook:
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Completing this form:
I am the student
Parent / guardian, on behalf of the student

2.  Allergies & Food Rules

Does the student have ANY food allergies or intolerances? *
No
Yes

Please list ALL allergies and intolerances in detail (write NONE if none):

Any foods avoided for religious, cultural, or dietary reasons (halal, kosher, vegetarian, etc.)?

3.  Vegetables

Which vegetables does the student LIKE? (check all that apply)
Broccoli
Carrots
Bell peppers
Tomatoes
Cucumbers
Lettuce / greens
Spinach
Corn
Green beans
Peas
Potatoes
Sweet potatoes
Onions
Mushrooms
Zucchini / squash
Cauliflower
Other vegetables the student loves:
Vegetables the student strongly dislikes or won't eat:

4.  Proteins

Which proteins does the student LIKE? (check all that apply)
Chicken
Beef
Turkey
Pork
Fish
Shrimp / seafood
Eggs
Cheese / dairy
Beans / lentils
Tofu
Deli meats
Peanut butter / nuts
Other proteins the student loves:
Proteins the student strongly dislikes or won't eat:

5.  Anything Else?  (optional)


Anything else that would make class great — favorite meals, textures or smells to avoid, support needs, or a dish you'd love to learn to cook:
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information
Completing this form:
I am the student
Parent / guardian, on behalf of the student

2.  Allergies & Food Rules

Does the student have ANY food allergies or intolerances? *
No
Yes

Please list ALL allergies and intolerances in detail (write NONE if none):

Any foods avoided for religious, cultural, or dietary reasons (halal, kosher, vegetarian, etc.)?

3.  Vegetables

Which vegetables does the student LIKE? (check all that apply)
Broccoli
Carrots
Bell peppers
Tomatoes
Cucumbers
Lettuce / greens
Spinach
Corn
Green beans
Peas
Potatoes
Sweet potatoes
Onions
Mushrooms
Zucchini / squash
Cauliflower
Other vegetables the student loves:
Vegetables the student strongly dislikes or won't eat:

4.  Proteins

Which proteins does the student LIKE? (check all that apply)
Chicken
Beef
Turkey
Pork
Fish
Shrimp / seafood
Eggs
Cheese / dairy
Beans / lentils
Tofu
Deli meats
Peanut butter / nuts
Other proteins the student loves:
Proteins the student strongly dislikes or won't eat:

5.  Anything Else?  (optional)


Anything else that would make class great — favorite meals, textures or smells to avoid, support needs, or a dish you'd love to learn to cook:
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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