CACFP Child Care Wellness Grant Application Page 1 of 8

Oregon Department of Education

Child Nutrition programs (ODE CNP)

Child and Adult Care Food Program (cacfp)

CACFP Child Care Wellness Grant

“Wellness Champions”

Grant Application

FDCH Sponsor

Instructions: Complete all sections and submit 1 copy of the application with original signatures and 4 copies of the application (total of 5 copies) by US Postal service or fax to:

Oregon Department of Education

Child Nutrition Programs

Attn: Hazel Randolph

255 Capitol St NE

Salem, Oregon 97310

Fax Number: 503-378-5156

Applications must be received by ODE CNP by 4:00 PM November 30, 2011.

Funding period: February 2012 – September 2013

The mini-grants will support CACFP centers and FDCH Providers in achieving three primary outcomes:

A. To identify, support and enhance the practices of CACFP center and FDCH Provider Child Care Wellness Champions and Emerging Champions which have demonstrated some success in implementing practices in one or more of the following 5 Key Strategies:

1. Increasing the amount and variety of fruit and vegetable consumption.

2. Increasing access to and consumption of healthy beverages.

3. Increasing accommodation for breastfeeding for children under age one.

4. Eliminating screen time.

5. Increasing the amount of adult-led structured physical activity.

B. To assist the Child Care Wellness Champions and Emerging Champions in sharing their success strategies and stories with other childcare centers and FDCH Providers in their communities.

C. To promote the CACFP through peer-education and outreach activities.

TIMELINE

The timeline table below shows the report due dates required by grant recipients.

Date: / Action:
February 1, 2012 / Pre-assessment checklist due to ODE
June 30, 2012 / Progress report regarding Key Strategies that FDCH Providers have implemented
December 30, 2012 / Progress report on peer education and outreach activities completed by FDCH Providers due. Progress report on continued implementation of Key Strategies (if applicable) due.
June 30, 2013 / Progress report on peer education and outreach activities completed by FDCH Providers due. Progress report on continued implementation of Key Strategies (if applicable) due.
October 30, 2013 / Final Progress report on peer education and outreach activities completed by FDCH Providers due. Progress report regarding continued implementation of Key Strategies (if applicable) due. Post assessment checklist due.

Oregon Department of Education

Child Nutrition programs (ODE CNP)

Child and Adult Care Food Program (cacfp)

CACFP Child Care Wellness Grant

“Wellness Champions”

Grant Application

FDCH Sponsor

SECTION 1: GENERAL INFORMATION

Sponsor’s Name ______

Sponsor’s CACFP Agreement # ______

Person Completing Application: Name and Title:______

Mailing Address:______

Email:______Telephone: ( _____ ) ______-______

Name of CACFP Food Program Coordinator:______

Email:______Telephone: ( _____ ) ______-______

Project Title:______

Goals and Design:______

Provide a brief summary (3 sentences) of the key strategies that are addressed and how the funds are used.

Grant Amount Requested: $______(maximum $15,000)

How many FDCH Provider(s) will you nominate as part of this project? (Enter the number of nominated providers.)

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_____ FDCH Provider(s)

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SECTION 2: Organizational Capacity

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Specify staff positions/titles responsible for the following CACFP Child Care Wellness Grant management functions:

CACFP Wellness Grant Function / Sponsor’s Staff Position(s)/Title(s)
Completing pre and post assessment checklist
Training staff involved in Child Care Wellness Grant implementation
Implementing and completing CACFP Wellness Grant Proposal
Monitoring progress on project activities
Monitoring Mentoring and Outreach activities
Communicating with FDCH provider wellness champions
Maintaining receipts and invoices to document use of mini-grant funds
Submitting reports to ODE CNP

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SECTION 3 –Provider Nomination Form

Please print, copy and complete Section 3 only for each FDCH Provider that you are nominating as a CACFP Child Care Wellness Champion.

NOMINATIONS:

Name of Provider:______

CNPweb Provider #:______

Is the Provider currently in “good” standing with the Sponsor?

This means that the FDCH Provider is not Seriously Deficient in the operation of the CACFP.

Yes No

What age groups of participants will be impacted by the project? (Check all that apply)

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Less that 1 year of age 1-2 years of age

2-5 years of age

6-12 years of age

12 -18 years of age Parents/guardians

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Provider nominated as

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Emerging Wellness Champion (implementing all 5 Key Strategies)

Emerging Nutrition Champion (implementing #1, 2, and/or #3 Key Strategies)

Emerging Physical Activity Champion (implementing #4 and/or #5 Key Strategies)

Check the Key Strategies (choose 1 or more) that will be implemented in the FDCH Provider’s home.

q #1 Increase the amount and variety of fruit and vegetable consumption for children in care.
Best Practices or Recommendations: Recommendations for food served to toddlers and preschoolers at child care:
· Offer a variety of different fruits (no juice) and/or vegetables at every meal
· Serve all meals family style
· Fried foods are rarely served
q #2 Increase access and consumption of healthy beverage options for children in care.
Best Practices or Recommendations: Recommendations for beverages served at child care for toddlers and preschoolers 1-5 years:
· Water is freely accessible both indoors and outdoors
· Water has no added sweeteners
· 100% juice is limited to 4-6 oz. daily
· Sugar-sweetened beverages including sports drinks are never served
· Milk served to children over the age of 2 is nonfat or 1% milk
q #3 Improve accommodations for breastfeeding if the center or home cares for children under the age of 1.
Best Practices or Recommendations: Recommendations for breastfeeding accommodation at child care:
· Encourage exclusive consumption of breast milk during the first 6 months of life.
q #4 Eliminate screen time (time spent using the television, videos, computers or video games).
Best Practices or Recommendations: Recommendations for screen time for preschoolers:
· Screen time should be limited to 30 minutes a week for preschool children in child care
· Screen time at home for preschool children should be limited to 1-2 hours per day of quality viewing
Best Practices or Recommendations: Recommendations for screen time for infants and toddlers:
· No screen time for 0-2 year olds
q #5 Increase the amount of structured (adult-led) physical activity for children in care.
Best Practices or Recommendations: Recommendations for physical activity for preschoolers:
· Preschool children should receive at least 60 minutes of structured activity and at least 60 minutes of unstructured active time each day
Best Practices or Recommendations: Recommendations for infants and toddler physical activity:
· Toddlers should be offered at least 30 minutes structured activity and at least 60 minutes of unstructured active time each day

SECTION 3 – Provider Nomination Form (continued)

Sponsor’s Name______Provider’s Name______

Write the Name of the Sponsoring Organization and the name of the Provider who is being nominated as a Wellness Champion.

For each Key Strategy checked on page 4 discuss the following (additional pages may be used, but limit additional pages for each Key Strategy to 1 page, 12 font; write the name of the sponsoring organization and the name of the Provider on all additional pages submitted.):

Planned activities to accomplish the Key Strategy in the FDCH provider’s home:

1.What best practices, strategies, policies and activities will be implemented in the FDCH provider’s home to achieve the Key Strategy checked?

2. Who will be responsible for the implementation of the best practices, strategies, policies and activities?

Resources that will be used to accomplish the Key Strategy:

1.What resources are already available for the FDCH provider to use to implement best practices, strategies, policies, and activities?

2.What resources will be purchased?

3. a. How will FDCH provider be trained to use the resources (if applicable)?

3.b. Who will conduct the training (if applicable)?

SECTION 3 – Provider Nomination Form (continued)

Sponsor’s Name______Provider’s Name______

Write the Name of the Sponsoring Organization and the name of the Provider who is being nominated as a Wellness Champion.

BUDGET/ BUDGET NARRATIVE

List anticipated expenditures for proposed activities related to implementing Key Strategies, peer-education activities and outreach activities in all nominated centers.

Enter the estimated budget for operating and administrative costs for the proposal. For Allowable Costs: Refer to FNS Instruction 796-2 Rev 3 and the enclosed “Allowable Costs” described in the RFP. Under the column headed “Funding Sources” include sources of funds that will be used in addition to Grant funds if applicable.

PROVIDER PROJECT OPERATING COSTS Total Amount Requested______

Line Item & Provide Details

Project Cost

Additional Funding Sources

Food purchases as part of an educational activity (Describe) / $
Small equipment used as part of a food demonstration project, hands on food activity which are part of nutrition education lessons. (List the type and amount) / $
Small physical activity equipment such as hula hoops, jump ropes, parachutes (List the type and amount) / $
Gardening activity supplies such as seed, potting soil, starter pots, small hand equipment such as spades, shovels, hoes, rakes (List the type and amount) / $
Curriculum (Give curriculum name and brief description) / $
Training on curriculum (describe: hours, materials) / $
Other (Describe) / $

Total Project Operating Costs

/ $

TIMELINE

Complete the dates for the items on Timeline Table below to highlight all major steps/activities of the project. Provide start date of project, implementation date of provider project activities such as training, purchase of materials, supplies and implementation date of peer-education/outreach activities.

Date: / Action:
Project start date
Training of FDCH provider (if applicable)
Implementation Date for Key Strategy activities
Implementation date for Peer Education and Outreach activities

SECTION 3 – Provider Nomination Form (continued)

Sponsor’s Name______Provider’s Name______

Write the Name of the Sponsoring Organization and the name of the Provider who is being nominated as a Wellness Champion.

Describe how the FDCH Provider will implement Peer Education and Outreach Strategies, share the Provider’s successes, and promote CACFP. (Additional pages may be used, but limit the pages to 2 pages, 12 font; write the name of the Sponsoring Organization at the top of all additional pages submitted).

Peer Education Strategies:

1. What methods will the FDCH provider use to serve as a peer educator to other providers in their immediate community for at least one year?

2. How will the FDCH provider serve as a peer educator to other providers in their communities?

3. How will the FDCH provider contribute to the Child Care Wellness Warehouse and promote the Warehouse to providers in their communities?

Outreach Strategies:

1. What outreach strategies will the FDCH Provider use to encourage providers who are not currently participating in CACFP to apply to participate in CACFP?

Publicity:

1. How does the FDCH provider plan to share the project activities in the community where the FDCH Provider operates?

Staff Training:

What staff training needs will be required to implement the project?

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SECTION 4: Sponsoring Organization’s Support (continued) Sponsor’s Name______

BUDGET/BUDGET NARRATIVE

List anticipated expenditures for proposed activities related to implementing Key Strategies, peer-education activities and outreach activities in all nominated centers.

PROJECT AMOUNT REQUESTED NUMBER OF PROVIDERS NOMINATED______

Source / Amount Requested / Additional Funding Sources
USDA Child Care Wellness Grant / $
Total Project Funds / $

PROJECT OPERATING COSTS TOTAL AMOUNT REQUESTED ______

Line Item

Project Cost

Additional Funding Sources

Food purchases as part of an educational activity / $
Small equipment used as part of a food demonstration project, hands on food activity which are part of nutrition education lessons / $
Small physical activity equipment such as hula hoops, jump ropes, parachutes / $
Gardening activity supplies such as seed, potting soil, starter pots, small hand equipment such as spades, shovels, hoes, rakes / $
Curriculum / $
Training on curriculum / $
Other (Describe) / $

Total Project Operating Costs

/ $

SPONSOR PROJECT ADMINISTRATIVE COSTS – limited to 15% of Mini-Grant Award

Project Costs

Additional Funding Sources

Administrative labor / $
Administrative services / $
Administrative supplies / $
Administrative transportation/monitoring mileage / $
Total Administrative Costs
/ $

TOTAL PROJECT COSTS

(Operating Costs plus Administrative Costs) CACFCosts.

ODE USE ONLY
□ Budget Approved □ Budget Denied Approved by:______

CONTACT INFORMATION

Contact Name:______Title:______

Email:______Telephone: ( _____ ) _____ - ______

We have reviewed this application and attest to the information provided. We have met and agreed upon a project plan. If selected, we agree to implement the program as outlined above and to implement the project in a manner consistent with the policies and procedures established by USDA. Further, we agree to participate in any USDA-sponsored evaluations and to provide the information and reports as requested by the specified deadlines. Please provide the contacts shown below or equivalent positions as determined by the school district. **Must be original signatures**

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SIGNATURES

______

Grant Director/Coordinator Name

______

Grant Director/Coordinator Signature

______

CACFP Authorized Representative Name

______

CACFP Authorized Representative Signature

______

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Date Date

For State Agency Use Only
*State Child Nutrition Director (signature) / Date

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