Nutrition Education Application

Which type of nutrition education services are you interested in?*

Choose all that apply.

Your name*

First Last

Your email*

Phone*

Site Information

Name of Site*

Site Address*

Street Address Address Line 2 City State ZIP Code

Has your site participated in a nutrition education service with Operation Food Search in the past?*

What class curriculum are you interested in?*

Does the site have a private meeting space large enough to accommodate at least 15 people?*

Does the private meeting space contain a working kitchen facility (sink, refrigerator, oven, etc)?*

What is your preferred day to host a nutrition education service?*

Choose all that apply

What is your preferred time to host a nutrition education service?*

Example: 11am - 2pm

What is your preferred start date?*

Do you have funding in place to host a nutrition education service?*

(Fees vary depending on the type of class and number of participants.)

How did you hear about us?

Any questions or comments?

Please input your initials as proof of signature:*

By signing this form, you attest that all above information is true to the best of your knowledge.

Date signed & submitted:*

Date