Nutrition Education Request Form

Disclaimer: This does not indicate you have booked an activity. A member of the Nutrition Education Team will follow-up with more detailed information and a confirmation once availability and eligibility have been established.

Agency Name:

Agency Phone Number:

Does your site/organization serve a primarily low-income audience? (At least 50% of your audience would need to be eligible for SNAP based on income. Program funding requires the Houston Food Bank to prioritize services benefiting low-income audiences.)

YesNo

Services Requested

For Low-Income Audiences:

Weekly Class SeriesMonthly Class SeriesFood DemoGrocery TourOne-time Class*Educational Materials* (e.g. handouts, recipes and stickers)

How many weekly class sessions?

How many monthly class sessions?

612

*Topic of Interest for One-time Class or Education Materials

Healthy Eating on a Budget	MyPlate
Fruits and Vegetables	Proteins
Whole Grains	Dairy and Calcium-Rich Foods
Reading the Nutrition Facts Label	Healthy Cooking Strategies
Healthy Meal Planning Strategies	Healthy Shopping
Healthy Fats	Healthy Hydration
Decreasing Added Sugar	Decreasing Sodium

For Professionals Serving or Impacting Low-income Audiences:

Food Insecurity and Health Training: Understanding the Issue and Engaging in SolutionsTrain-the-Trainer Workshop: How to Implement Successful Nutrition Education InterventionsTailored Health Plan or Partnership: Initial MeetingHealth and Nutrition Consult: Assistance with the development of policies, environments and systems promoting healthful eating access and behaviors.

Target Audience: Kids (5-12)Teens (13-17)ParentsAdults (18+)Seniors (60+)Other, please specify
Other

Language Preference:

EnglishSpanish

Number of Expected Participants:

Preferred Day:

Preferred Time:

Address of Requested Activity:	City
State	Postal Code

Primary Contact's Name:

Primary Contact's Number:

Primary Contact's Email

Questions or Comments: