Consumer Research for Nutrition Educatoin and Promotion Activities (SLT)

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

EAT SMART. PLAY HARD.™
POWER PANTHER™ COSTUME REQUEST AND AGREEMENT FORM
There is a 2-day limit on costume loans
Complete the following and send by e-mail or fax to your regional representative.
Title:

Contact Person:
Department:

Agency:

Program:

Address:

Suite/Room:
State:

City:
Contact Phone:

Fax:

Zip:
Email:

ABOUT YOUR AGENCY
USDA nutrition assistance program(s) you administer:
NONE
School Meals (NSLP/SBP)
Supplemental Nutrition Assistance Program (Food Stamp Program)
Women, Infants and Children (WIC)
WIC Farmers Market
Food Distribution Program on Indian Reservations (FDPIR)
Child and Adult Care Food Program (CACFP)
Summer Food Service Program (SFSP)
The Emergency Food Assistance Program (TEFAP)
Commodity Supplemental Food Program (CSFP)
Other (specify)

Type of requesting agency (check only one):
FNS Region
State Agency
Local Agency
County
Other (specify)

FORM FNS-807 (06-16) Previous Editions Obsolete

SBU

Electronic Form Version Designed in Adobe 10.0 Version

ABOUT THE EVENT
What do you want to achieve by involving Power Panther™ in your event?

Event Date
Event Location (City, State, Zip)
Type of Event:
School-based
Community-based
Game or Sports Event
Food Store
Health Parade/Walk/Hike/Race
Celebrations
Other (specify)
Event Sponsor/Host (e.g., WIC Clinic)
Target Audience (Age/Grade level)

Participation Estimate (Number expected)

Key Activities:
Nutrition Education
Physical Activity
Health Screenings
Food Tasting
Computer Lab
Other (specify)

CERTIFICATION
I,
, 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 accept full liability for injury to persons or property connected with the use of the costume. I have read all the material
provided, agree to the terms and conditions stated. I will return the costume on the date required and in the condition which it was
received. I will not photograph Power Panther™ with food brands or other industry mascots.

Signature of Agency Representative

Title

Date

For FNS Use Only
Request is from an agency that operates a FNS program.

YES

NO

Education activities are included as part of this event.

YES

NO

Is this request for more than 2 days use?

YES

NO

Approved

Disapproved

Approving Official:

Name

Title

Date

Check your location:
HQ

NERO

MARO

SERO

SWRO

MWRO

MPRO

Mid-Atlantic Regional Office
Public Affairs Office
300 Corporate Blvd.
Robbinsville, NJ 08691
Ph: 609-259-5026
Fax: 609-259-5011
States: DE, DC, MD, NJ, PA, PR, VA, VI, WV

Southeast Regional Office
Public Affairs Office
61 Forsyth Street, SW, Room 8T36
Atlanta, GA 30303-3427
Ph: 404-562-1811
Fax: 404-527-4502
States: AL, FL, GA, KY, MS, NC, SC, TN

Midwest Regional Office
Special Nutrition Programs
77 W. Jackson Blvd., Suite 2000
Chicago, IL 60604
Ph: 312-353-1902
Fax: 312-353-1706
States: IN, OH, MI, WI, IL, MN

Southwest Regional Office
Special Nutrition Programs
1100 Commerce Street, Room 522
Dallas, TX 75242
Ph: 214-290-9800
Fax: 214-767-5522
States: AR, LA, NM, OK, TX

Mountain Plains Regional Office
Public Affairs Office
1244 Speer Blvd., Suite 903
Denver, CO 80204
Ph: 303-844-0313
Fax: 303-844-6203
States: CO, IA, KS, MO, MT, NE, ND, SD, UT, WY

Western Regional Office
Public Affairs Office
90 Seventh Street, Suite 10-100
San Francisco, CA 94103
Ph: 415-705-1311
Fax: 415-705-1364
Email: [email protected]
States: AK, AZ, CA, HI, ID, NV, OR, WA

WRO

Northeast Regional Office
Public Affairs Office
10 Causeway Street, Room 501
Boston, MA 02222
Ph: 617-565-5300
Fax: 617-565-6473
States: CT, MA, ME, NH, NY, RI, VT

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond
to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0584-0524. The time required to complete this information collection is estimated to average 15 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