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 Registration & Order Form

Congratulations on becoming a champion for change by partnering with the Children’s Power Play! Campaign.  To get started, simply complete and submit this form to your Children’s Power Play! Campaign Coordinator to receive your Community Youth Organization Idea & Resource Kit and other materials. Once the form is submitted, you will receive a confirmation page that you may print for your records.

Contact First Name:
Contact Last Name:
Contact Title:
Organization Name:
Site Name:
Site Address:
City:
Zip:
County:
Phone:
Fax:
Email:
The best way to reach me is:
Mail Email Phone Fax
# of participating 9 to 11 year olds

Children's Power Play! Resources (Please order below.)

Youth Leader Pack
Includes 1 Community Youth Organization Idea & Resource Kit, 1 poster, 1 English-Language Parent Brochure, 1 Spanish-Language Parent Brochure. If you still have your Community Youth Organization Idea & Resource Kit (© 2005 or later), please order parent brochures only.
For the next section, please enter the number of packs of 35 brochures in the space provided.
packs of 35 of the English-Language Parent Brochures
 This full-color brochure is designed to give parents of elementary age children ideas for helping their kids eat more fruits and vegetables and be more active.  The brochure is available in packs of 35.
packs of 35 of the Spanish-Language Parent Brochures
 A Spanish-Language version of the Campaign’s parent brochure.  The brochure is available in packs of 35.

Commitment Statement (Please check statement.)
   I want to be a champion for change in my school!  I commit to completing the Children’s Power Play! Campaign Community Youth Organization Idea and Resource Kit with my students and to submit my CYO Participation Report to my Children’s Power Play! Campaign Coordinator. (To view the CYO Participation Report, click here.  A new window will open.)
 

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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