JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Take Back The Kitchen: Interest Form
Please fill out the following form. Once we receive your response we will be in touch within a week with further details and questions. Thank you for your interest in our program.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Organization Name:
*
Your answer
Program Name (if applicable):
Your answer
Organizational Mailing Address
*
Your answer
Contact Name and Title
*
Your answer
Contact Phone
*
Your answer
Contact Email
*
Your answer
Brief description of your organization (1-2 sentences):
*
Your answer
How many students will attend? (Ideal class size is 8-12 students)
*
Your answer
Tentative Age Range of Students
*
Your answer
Are you interested in a one-time class or a series of classes ? (If a series, the same group must attend all classes in the series)
*
One time class
Series of 6 classes
Series of 8 classes
Series of 10+ classes
The cost per class is $500. Haley House has limited funding available to support classes for organizations working with students in our target populations. How are you able to contribute?
*
We have funding available to cover the full cost.
We have funding available to cover some of the cost.
We do not have funding to cover this cost.
Other:
Required
We have found that classes work best if they are held in one of our Haley House Kitchen Spaces (Teaching Kitchen at our Bakery Cafe in Roxbury ).
Classes typically run for 2 Hours. Please share any specific dates and times slots that would work best for your organization ?
*
Your answer
Please provide name, cell and email for the 1 or 2 chaperone(s) in charge of the participants:
Your answer
IMPORTANT: Each group is responsible for providing their own transportation and chaperones (1-2 per group). Please share your plan for these things below. If you are not able to provide a transportation and supervision plan, unfortunately we will not be able to accommodate your group.
*
We have transportation and chaperones available for our class(es).
Students will be walking and/or taking public transportation, and we have chaperones available.
All members of our class are 18+ and will be responsible for their own transportation
Other:
What are you hoping the students will gain from participating in this program?
*
Your answer
Are there any specific topics you’d like us to consider as part of the curriculum. Examples of our prior class themes.
*
Cooking basics: Kitchen safety / knife skills / Ingredient (vegetable) Identifications
Nutrition 101: How to build a nutrient dense plate - Upgrade your dinner plate: Upgrading your favorite comfort foods to a healthier version
Nutrition Basics: How to eat healthy using the basic ingredients.
Seasonal cooking: Cooking throughout the season.
Other:
Required
Can you tell us a little bit more about the participants?
Your answer
Please share any other questions or concerns.
Your answer
Please list any food allergies for this group. If you are not able to do this now, please email Program Manager Sisi Jeanbaptiste (
sjean-baptiste@haleyhouse.org
) at least 5 days before the first class, so the chef can choose appropriate recipes.
Your answer
Haley House works with PEAR to facilitate youth surveys for organizations that engage in series that are six sessions or longer with our organization. Is your organization willing to share the name and age of youth program participants?
*
Yes
No
Can you please provide us with the best name and email address to send the MOU to?
*
Your answer
Can you please provide us with the best name and email address to send an invoice to?
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
