APPLICATION

Nurturing Nature Through the Foods We Eat

Please fill in completely. All applications due to:

Action for Children, c/o Betsy Loeb,

78 Jefferson Ave., Columbus, OH 43215 or

Email:

Please return no later thanFebruary 25, 2011.

Thank you!

Reasons why I want to participate:

1. Tell us why you would like to participate in this program.

2. Rate parent involvement at your program. ____high____medium____low

Explain:

3. State specifics about what changes you might think would occur for you &/or your program…including children, parents &/or yourself as a result of your participation in this program.

A committee will review each application. All applicants will be notified of acceptanceno later than3/11/11.

Applicants will be selected based upon a combination of date registration received, reasons for participating, and strong commitment of 2 persons applying (preferred).

***********************Continue Application on Back *********************

Name: ______

*OPDN - 8 digit OPIN -

*All participants must have an account on the Ohio Professional Development Network. If you do not have an account/Registry Profile, go to ( and click blue box to “Sign Up for OPDN.” Follow prompts to set up account. A unique 8 digit OPIN will be assigned to you. Enter in boxes above. OPDN help desk phone (877)547-6978

Name of Program:______

Street Address:______City:______State:____ Zip:______

Bus. Phone:______Home Phone:______Cell Phone:______

Email: ______ Fax: ______

Please check the best way you can be reached:

_____Postal mail _____Email_____Business phone_____Home phone_____Cell phone

I work with: ______K______Grades 1-3______Grades 4 & 5 ______Mixed school-age group

My program is (check all that apply): ______21st Century ______For-profit ______Non-profit

______School-based ______Childcare Center-based ______Community-based _____Faith-based

Enclose individual checks made payable to Action for Children:

(please write program name in memo – Nurturing Nature Through the Foods We Eat)

$20 deposit ______(Check will be deposited if applicant is approved for participation.)

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I understand that my participation in this new Nurturing Nature Through the Foods We Eat requires that I fully participate in all program phases from March through November 2011. This requirement includes:

*attend all 10 hour-curriculum (2.5 hrs monthly: Mar 25, Apr 29, Sept 16 & Oct 21—10:00am-12:30pm)

*apply lessons from each session into my work by completing suggested homework assignments

*connect with an AfC Technical Advisor at least twice during the project year for on-site support

*recruit at least one parent & student to participate inone field trip programto a designated farm (dates TBD)

*attend two (2) field trips – 1 with educators only; other, with parents & students from above - at a designated farm (TBD)

*participate in all phases of evaluation process of Nurturing Nature Through the Foods We Eat(Begins early March)

Print Name: ______

Signature:______Date: ______

As the administrator (if applicable) of the above named person, I approve of his/her participation in the entire Nurturing Nature Through the Foods We Eat.

PrintName:______

Signature: ______Date:______