SA/LA - User Response, Feedback, and Request Forms

Attachment 4

Power Partner Commitment Form

Eat Smart. Play Hard.™

The Food and Nutrition Service invites you to become an Eat Smart. Play Hard.™ Power Partner. Complete this form and check what your agency will do over the next 12 months to promote healthy eating and physical activity behaviors. Email this form to [email protected] or fax it to 703-305-2576, Attention NSS.

Primary Contact __________________________ Title _______________________________

Organization/Dept. _______________________ Agency/Division ______________________

Address: ______________________________________________________________________

City: ___________________________ State: ______ Zip: __________________________

Phone: _____________ Fax: ________________ Email: _____________________________

Secondary Contact _________________________ Title _____________________________

Organization/Dept. ________________________ Agency/Division ______________________

Address: ______________________________________________________________________

City: ___________________________ State: ______ Zip: ________________________

Phone: _________________ Fax: ________________ Email: ____________________

ABOUT YOUR AGENCY

Which USDA nutrition assistance program(s) does your agency administer? Check all that apply.

[ ] NONE [ ] Child Nutrition/School Meals [ ] Food Stamp Program

[ ] WIC [ ] WIC Farmers Market [ ] FDPIR

[ ] CACFP [ ] Summer Food Service Program [ ] TEFAP

[ ] CSFP [ ] Other – specify ____________________________________

Type of requesting agency: [Check only one]

State Agency ____ Local Agency ____ Other, specify___________

Check all that apply. As an Eat Smart. Play Hard.™ Partner, we will:

Complete the Choice A or B of the Basic Requirements and at least 2 optional requirements from _(date)__ to_(date)__ (must be completed in 12 months).

Basic Requirements:

• Choice A

• conduct 3-4 lessons for kids (including the take home and community components),

• sponsor at least one education/community wide program featuring Power Panther * that uses the Power Panther scripts, stories, and Power Up Moves,

• conduct a tour of the kids’ Eat Smart. Play Hard.™ website. Have kids work in groups to provide feedback on each of the eight locations in the virtual community.

• conduct 1-2 Power Plan lessons for Parents.

• Choice B

  • conduct 1-2 lessons for kids (including the take home and community components),

  • sponsor at least one education/community wide program featuring Power Panther * that uses the Power Panther scripts, stories, and Power Up Moves,

  • conduct 3-4 Power Plan lessons for Parents.

Note: The activities in either Choice A or B must be completed during a 6-8 week period of time to maximize impact.

Optional Requirements (Check at least two):

• Host a family “food tasting” night to make family members aware of the

important role they play in promoting healthy eating and an active living environment; share resources and tips and conduct a tour of the parent web pages and resources. Include a taste test of the healthy, tasty, easy, and low cost recipes on the site.

• Conduct additional education sessions with children and or adults using the Power Plans or FNS My Pyramid for Kids lesson plans.

 Conduct (# ) events using Power Panther*, the Power Panther scripts and

related resources.

• Feature an article on Eat Smart. Play Hard.™ in our publications.

• Play the audio Eat Smart. Play Hard. ™ PSAs

• Create a dance routine with our kids using the Power Panther songs.

• Encourage our band to learn and play the Power Panther song at school assemblies.

• Conduct trainings for staff on new Eat Smart. Play Hard.™ resources.

• Include a link to Eat Smart. Play Hard.™ on our website.

• Other, please describe________________________________________

* Submit Costume Request and Agreement Form for your event at least 6-8 weeks in advance.

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___________________ ___________________________ _________________________

Date Name (print or type) Signature

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