Health and Wellness Site Activity Application
If this is your first time requesting a program, please answer all questions. If you have requested a program in the past, you only need to answer the questions marked with the red asterisk.
Name of Organization *
Your answer
Organization Website
Your answer
Street Address
Your answer
City
Your answer
County
State
Zip Code
Your answer
Primary Contact Person *
Your answer
Job Title
Your answer
Phone Number *
Your answer
Fax Number
Your answer
E-Mail *
Your answer
1. Is your organization a member of the Food Bank of South Jersey (FBSJ)?
2. Has your organization partnered with the FBSJ in the past?
3. How did you hear about the FBSJ Health and Wellness Department?
4. How do you classify your organization?
5. Does your organization serve low-income individuals?
6. Do your clients receive food or nutrition assistance (WIC, SNAP/Food Stamps, Senior Farmer's Market, CSFP, etc.)?
7. How would you rate participation levels among clients for workshops offered by your organization?
8. Briefly describe your organization's work and mission.
Include the types of services and programs you offer to your clients.
Your answer
9. Please select the first activity that you are interested in hosting at your organization. *
Please select only one activity. This form allows you to apply for one activity and an alternate activity. If you would like the Food Bank of South Jersey to host an information table at your event, contact Volunteer Services at volunteers@foodbanksj.org , or call (856) 662-4884.
10. Please indicate the date and time you would like to begin the first activity. *
We request at least 2-4 weeks of lead time to schedule all activities. Activities can be scheduled Tuesday - Saturday.
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11. Please provide an alternate date and time to begin. *
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12. Who do you expect to participate in the activity? Check all that apply. *
Required
13. How many individuals do you expect to participate? *
Your answer
14. Is there anything else you would like us to know about the participants?
Your answer
15. Please select an alternate activity. We will attempt to schedule this second activity if we are unable to schedule the first.
Please select only one activity. This form allows you to apply for one activity and an alternate activity.
16. Please indicate the date and time you would like to begin the second activity.
We request at least 4-6 weeks of lead time to schedule all activities.
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17. Please provide an alternate date and time to begin.
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YYYY
Time
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18. Who do you expect to participate in the activity? Check all that apply.
19. How many individuals do you expect to participate?
Your answer
20. Is there anything else you would like us to know about the participants?
Your answer
21. Please indicate in which county the activity will be held. Do not use the address of your main office unless it is the class location. *
22. Please describe the space where you would like to hold the activity. Check all that apply. *
Required
23. How do you plan to fund the requested programming? Purchase orders (P.O.s) are accepted. *
24. Is your organization funded through any of the following sources? *
Required
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