Request Form for Food Allergy and Intolerance Survival Guide

Required fields are marked with a *

* Name
Business
* Address 1
Address 2
* City
* State	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
* Zip Code
Phone	- -
* Email

1. Who in your family is on a restricted diet? choose all that apply:

me partner child no one

2. Which foods does your family avoid? choose all that apply:

wheat gluten peanuts tree nuts soy eggs dairy casein corn sulfites potato other (please specify)

3. Which best describes your family's reason for food avoidance?

food allergy celiac disease food intolerance autism ADHD allergy prevention other (please list below)   other

4. Are you familiar with Enjoy Life™?

Yes    No

If Yes, how did you learn about Enjoy Life™?

magazine friend ND MD RD saw it in the store other

5. Are you familiar with Perky's Cereals?

Yes    No

If Yes, how did you learn about Perky's Cereals?

magazine friend ND MD RD saw it in the store other

6. Would you like to join our mailing list to qualify for a big 'ol Enjoy Life goody bag (winner drawn monthly) and receive new product alerts and tasty recipes? Don't worry we won't share or sell your information.

yes, please add me to your mailing list no thanks

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