Nutrition Education One Time Event Request 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 SureRequested Date of Event Requested Time of Event Requested Length of Event30 minutes45 minutes1 hour1.5 hours2 hoursMore than 2 hoursIf the event is not yet scheduled, please indicate the day(s) of the week that would work best. (check all that apply) Monday Tuesday Wednesday Thursday Friday If the event is not yet scheduled, please indicate the time(s) of day that would work best. (check all that apply) Morning Afternoon Evening Topic(s) Requested Cooking Eating Healthy on a Budget Food Safety Limiting Added Sugar, Fat and Sodium MyPlate/Food Groups Meal Planning Physical Activity Reading the Nutrition Facts Label Other (please list below) Untitled Would you like the event to include a food demonstration?YesNoNumber of Participants Expected Target AudienceChildrenTeensAdultsSeniorsOther (please list below)Untitled Language (check all that apply) English Spanish
