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

Attachment 5

Power Panther™ Costume Request and Agreement Form

Eat Smart. Play Hard.^™

Complete the following and send by email or fax to your regional representative.

Department: ____________________________ Agency: __________________________

Contact Person: _________________________ Title: ___________________________

Division: ____________________________ Program:_____________________________

Address: ________________________ Suite/Room:___________________________

City: ____________________________ State: _______________ Zip: __________

Contact Phone:____________Fax:___________ Email:____________________________

ABOUT YOUR AGENCY

1. 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]

_____ FNS Region ______State Agency _____ Other, specify___________

_____ Local Agency ______ County

ABOUT THE EVENTS

1. Check all Eat Smart. Play Hard.™ materials you will use in conjunction with Power Panther’s visit. All of the following materials are available at: http://www.fns.usda.gov/eatsmartplayhard/Zone/bio.html

Type of Materials	Name of Material	Check All Items to be Used
Power Panther™ script:	Eat Smart. Play Hard™ with MyPyramid;
	Eat Smart. Play Hard™ in School;
	Learn to Eat Smart. Play Hard ™ with Power Panther™
Eat Smart. Play Hard™ Lesson Plans:	Taste the Colors
	Snack Smart
	Power Up with Breakfast
	Choose Drinks that Count
Power Panther™ Song:	If you wanna to be like the Power Panther™
	Power Panther™ is Here
Power Panther ™ Exercise	Power Up Moves
Others Materials:	Activity Sheets
	Kids Website
	Comics
Others - Specify

What do you want to achieve by involving Power Panther in your event(s)? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Complete the following Schedule of Events Chart for your Power Panther Event(s). There is a two (2) day limit on the costume loan.

Instructions: Provide information about each event scheduled for Power Panther using the codes below. You can download this form as a MS word file on

our web site for electronic submission: www.fns.usda.gov/eatsmartplayhard

Date - Enter date of each event. List events in the order you plan to conduct them.

Type of Event - Use these codes for type of event: (Select one)

• School-based (S), Community-based (C), Game or Sports Event (GS), Faith-based (FB), Food Store (FS), Health (H), Parades, Walks, Hikes, Races (PA), Celebrations, examples: School Breakfast or Lunch Week, Fruit & Veggie Month, etc. (CA), Other – Specify (O)

Sponsor - Enter the FNS sponsor or host of the event: For example WIC, FSP, FDPIR, WIC, FMNP, SFMNP, CNP, etc.

Target Audience - Enter age or grade levels for kids, or specify adults-example: kids 8-10 or grades 3-5.

Participation Estimate - Enter number of kids and adults expected. Location of event - Enter city, State, and zip code of each event.

Key activities - Use these codes for type of activity (Select up to 3):

• Nutrition Education (NE), Physical Activity (PA), Health Screenings (HS), Food Tasting (FT), Computer Lab using Eat Smart. Play Hard™ Website, interactive games, etc.(CL), Other - Specify (O)

Date of Event	Type Event (use above codes)	Sponsor(s) WIC, FSP, etc.	Target Audience	Participation Estimate		Location of Event			Key Activities (Use above codes)
				#Kids	#Adults	City	State	Zip Code

Certification

I/We _________________________ have read the Guidelines for Power Panther™ and His Helper and agree to use the Power Panther™ costume in accordance with the criteria and only for promoting healthy eating, physical activity, and USDA nutrition assistance programs. I/We accept full liability for injury to persons or property connected with the use of the costume. I/We have read all the material provided, agree to the terms and conditions stated. I/We will return the costume on the date required and in the condition that it was received. I/We will not photograph Power Panther with food brands or other industry mascots.

_______________________________ __________________ ________________

(Signature of Agency Representative) (Title) (Date)

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