Agency/Organization Name Date MM slash DD slash YYYY Agency Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Delivery Address (if different from above) Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCĂ´te d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRĂ©unionSaint BarthĂ©lemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTĂĽrkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweĂ…land Islands Country Name of Main Contact for This Program First Last Job Title PhoneFaxEmail What is the primary function of your agency/organization?Examples: school, church, community center, wellness center, housing development, food bank, etc.Briefly describe your organization’s work and mission. Include the types of services, programs, trainings, etc. you offer.Because Cooking Matters programming serves individuals with low incomes, you must demonstrate that at least 50% of your participants meet low-income requirements. What are some programs individuals you serve participate in (check all that apply)? Select All Basic Food Benefits TANF (Temporary Assistance for Needy Families) GA (General Assistance) SSI (Supplemental Security Income) Eligible for free/reduced-price school meals Medicaid enrollment for adults (income limits for Medicaid for children are higher) SFMNP (Senior Farmers Market Nutrition Program) Head Start or ECEAP (Early Childhood Education Assistance Program) WIC (Women, Infants, and Children) Other If "other," please specify: General Participant InformationList languages spoken by those who might participate in Cooking Matters:Any other information about those who might participate in Cooking Matters that might be helpful to know?How did you hear about the Cooking Matters program?Have you observed a Cooking Matters class? Yes No If yes, please provide the following information:Course Name Class Location (e.g., agency/organization name)Class Location (e.g., agency/organization name) What type(s) of curricula are you interested in hosting? Adults Kids (ages 8-12) Elementary aged kids & parents/guardians together Teens (ages 13-17) Young parents Parents of young children Has your agency led nutrition education or wellness programming in the past? If so, please describe.Does your organization have classroom space large enough to accommodate 8–15 people?If not, this does not automatically disqualify you from hosting classes. Yes No Does your organization have access to a working kitchen facility? Yes No Kitchen includes (check all that apply): Select All Sink with hot water Working oven Working stove (burners) Refrigerator Other If "other," please specify: Does your organization have funds to purchase food for in-class recipes and take-home groceries?If not, this does not automatically disqualify you from hosting classes. Yes No Does your organization currently have a van (or other means of transportation) and valid insurance for transporting participants to and from your site and/or other locales, for a grocery store visit?If not, this does not automatically disqualify you from hosting classes. Yes No Cooking Matters can provide agencies with flyer designs to assist with recruitment; however, it is each agency’s responsibility to recruit the class participants. What is your current method of recruiting participants for various programs? Flyers Phone Calls Mailings Newsletter Other If "other," please specify: How would you rate participation levels for community service programs offered at your facility? High (100% - 80%) Moderate (79% - 50%) Low (49% - 20%) Cooking Matters requires agencies to provide childcare for children of adult participants when necessary. Does your agency currently have this capability?It is dangerous to have children in a classroom with sharp knives/burners/etc. Yes No Your commitment to hosting Cooking Matters classes is integral to the overall success of this program at your agency. Are you willing and able to be actively involved in recruiting participants, be present during classes, and assist with class preparation and other class needs? Yes No Δ