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Nutrition Education Request Form
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* Required
Email
*
Your email
Agency Name
*
Your answer
Are you an ACFB Partner Agency?
*
Yes
No
If yes, what is your ACFB agency I.D. number?
Your answer
What services does your agency/program provide to the community?
Food pantry
Hot or cold meals
CSFP boxes (seniors)
Food Co-op
Child care
Clothing
Other:
Who is the point of contact?
*
Your answer
Email Address
*
Your answer
Phone number
*
Your answer
Location for request: Address, City, State, Zip
*
Your answer
Primary language of participants
*
Your answer
If other than English, will there be a translator available?
*
Yes
No
Are there any specific cultural/religious practices of participants related to food? If yes, please specify next to "Other".
*
Yes
No
Other:
Required
Should written materials be provided in a language other than English? If yes, please specify next to "Other."
*
Yes
No
Other:
Required
# of expected participants
*
Your answer
Age range of participants
*
Your answer
Top 3 available dates and times
*
Please separate dates on different lines - be sure to include the time requested
Your answer
Type of education desired
*
Hands On Cooking class in The Learning Kitchen at ACFB (max 20 people)
Cooking Demonstration at your site
Interactive Display Set-up
Presentation
Cooking Matters workshop (nutrition and cooking workshop that meets weekly for 6 weeks) at Learning Kitchen at ACFB
Cooking Matters workshop (nutrition and cooking workshop that meets weekly for 6 weeks) at your site
Other:
Required
If requesting a cooking demo at your site, does your agency have the following? (check all that apply)
*
Live socket
Demonstration table (not required)
Trash can
Kitchen (not required)
Required
Topics of Interest (note that all may not be covered based on time)
*
Nutrition Label Reading
Nutrition 101 (The Basics)
Pop-Up Grocery Store Tour (Shopping on a Budget)
Food Safety for your Health
Nutrition for Heart Health and High Blood pressure
Fruit and Vegetable Preservation
Nutrition for Kids
Nutrition and Diabetes
Required
Is your agency interested in providing benefit screening and application services (i.e., SNAP, Medicaid/Medicare, etc.) for your participants?
Yes
No
Clear selection
Please provide any additional notes that are important for planning:
Your answer
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