Network for a Healthy California--Gold Coast Region
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Carolina Ugarte, MSW
Children’s Power Play! Campaign Manager

Network for a Healthy California— Gold Coast Region
Ventura County Public Health
2323 Knoll Drive, Suite 305
Ventura, CA 93003
Phone: 805.677.5262
Fax: 805.677.5220
carolina.ugarte@ventura.org

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Gold Coast Region :: Power Play! Campaign Community Youth Organization Participation Report

Thank you for being a champion for change for children! By returning this form, you’ll help to ensure that the Children’s Power Play! Campaign continues to receive funding to improve the health of California’s children. Once the form is submitted, you will receive a confirmation page that you may print for your records.

Contact First Name:
Contact Last Name:
Title:
Organization Name:
Site Name:
Site Address:
City:
Zip:
County:
Phone:
Fax:
Email:
# of participating 9 to 11 year olds

Please complete the following:

indicates nutrition education activities indicates physical activity education activities
Kit Activity Name
Check off if completed:
Kit Activity Name
Check off if completed:

1. Power Bingo

1. Fixin' Fruits & Veggies

2. How Much Do I Need?

2. Grow Your Own

3. Warm Up for Power

3. Taste It!

4. Power Tag

4. Advertising Power

5. Memory Ball

5. Movin' & Groovin'

6. Fruit & Vegetable Name Game

6. Powerful Art

7. Rainbow Mysteries

7. Field Trip Power

8. Grab the Flag

8. Power Up Challenge

9. Color Tag

9. Hoop Challenge

10. Memory Movement

10. Fitness Circuit Challenge

Did you use any other nutrition education resources?

Harvest of the Month

Other USDA Team Nutrition resources

Nutrition Decathlon

Other:

USDA's The Power of Choice

Other:

How has Power Play! made a difference in your site? (Additional comments welcome)


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For CalFresh information, call 1-877-847-3663. Funded by the USDA SNAP, an equal opportunity provider and employer. Visit www.cachampionsforchange.net for healthy tips.
California Department of Public Health