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 School 4th & 5th Grade Teacher Participation Report

Thank you for being a champion for change for your students! 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.

Teacher First Name:
Teacher Last Name:
School Name:
District Name:
School Address:
City:
Zip:
County:
Phone:
Fax:
Email:
# of 4th Grade students participating in Children's Power Play! Campaign activities
# of 5th Grade students participating in Children's Power Play! Campaign activities
Yes, I would like to receive Power Play! materials for next year! (School Year 2011-2012)

Please complete the following for 4th and/or 5th Grade:

4th Grade Kit Activity
Check off if completed:
5th Grade Kit Activity
Check off if completed:

1. Power Survey

1. Power Survey

2. Power Search

2. Power Scramble

3. How Much Do I Need?

3. How Much Do I Need?

4. Power Choices

4. Making Better Choices

5. Fruit & Vegetable and Power Play Journal

5. Fruit & Vegetable and Power Play Challenge

6. My Power Plan

6. You Be the Food Critic!

7. Rate the Taste

7. The Power of Advertising

8. The Power of Advertising

8. What's on a Label?

9. What's on a Label?

9. Plan a Power Meal

10. Healthier Please!

10. I Have Power!
Did you use any other nutrition education resources?

Harvest of the Month

Team Nutrition

Power Up for Learning

Store Tour

Nutrition Decathlon

Other:

How has Power Play! made a difference in your classroom? (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