Nutrition Education Material Request Form Organization Name* Address* Primary Contact Name* Primary Contact Phone Number*Primary Contact Email Address* Is at least 50% of your audience considered low-income?*YesNoNot SureType of Nutrition Education Material Requesting (check all that apply) Handouts Recipes Other (please list below) If requesting handouts, what topic(s) would you like to receive? (check all that apply) Breakfast Eating Healthy on a Budget Food Safety Healthy Snacks Limiting Added Sugar, Fat and Sodium MyPlate/Food Groups Meal Planning Physical Activity Reading the Nutrition Facts Label Other (please list below) If requesting recipe cards, please list specific foods (if any) you would like to be included in the recipe ingredients.Language of Materials (check all that apply) English Spanish Total Number of Clients seen per month
