Healthy Living Initiative 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
Burlington, Camden, Gloucester or Salem
Your answer
State
Your answer
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 Healthy Living Initiative?
4. How do you classify your organization?
5. Does your organization serve low-income individuals?
6. Do your clients receive WIC, SNAP or other nutrition assistance?
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 two activities total.
10. Please indicate the date and time you would like to begin the first activity.
We request at least 4-6 weeks of lead time to schedule all activities.
MM
/
DD
/
YYYY
Time
:
11. Please provide an alternate date and time to begin.
MM
/
DD
/
YYYY
Time
:
12. 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.
13. Please select the second activity that you are interested in hosting at your organization.
Please select only one activity. This form allows you to apply for two activities total. If you would like to apply for more than two, please complete and submit another application.
14. 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.
MM
/
DD
/
YYYY
Time
:
15. Please provide an alternate date and time to begin.
MM
/
DD
/
YYYY
Time
:
16. 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.
17. Please describe the space where you would like to hold the activity. Check all that apply.
Required
18. How do you plan to fund the requested programming?
If you requested a Tower Garden Installation, please go here to complete a short questionnaire: https://docs.google.com/forms/d/e/1FAIpQLScttLwSRZuMPv289jn9VNA8Cy5rs-aYbmAmPuP_hjxaoNcgwQ/viewform You will be able to return to this tab to submit your application after completing the questionnaire.
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms