FNS-807 Power Panther Costume Request and Agreement Form Eat Sma

OMB APPROVED NO. 0584-0524
Expiration Date: XX/XX/XXXX

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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:

Contact Phone:

Fax:

Zip:

Email:

ABOUT YOUR AGENCY
1. Which USDA nutrition assistance program(s) does your agency administer? Check all that apply.
[ ] NONE
[ ] WIC

[ ]
[ ]

Child Nutrition/School Meals
WIC Farmers Market

[ ]
[ ]

Food Stamp Program
FDPIR

[ ]

CACFP

[ ]

Summer Food Service Program

[ ]

TEFAP

[ ]

CSFP

[ ]

Other – specify

Type of requesting agency: [Check only one]
FNS Region
Local Agency

State Agency
County

Other, specify

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
Check All Items
to be Used

Type of Materials

Name of Material

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

Power Panther™ Song:
Power Panther™ Exercise
Other Materials:

Choose Drinks that Count
If you wanna be like the Power Panther™
Power Panther™ is Here
Power Up Moves
Activity Sheets
Kids Website
Comics

Others - Specify
Form FNS-807 (03/10) Previous Editions are Obsolete

SBU

Electronic Form Version Designed in Adobe 10.0 version

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

3. 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 Sponsor(s)
Target
(use above WIC, FSP,
Audience
codes)
etc.

Participation
Estimate
#Kids

Key Activities
(Use above
Zip Code
codes)

Location of Event

#Adults

City

State

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)

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research
and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0524). Do not return the completed form to this address.