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I. BACKGROUND INFORMATION
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Organization Name:
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Organization or Agency Web Adress(es):
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Program Name:
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Program Type:
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Physical Activity
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Nutrition
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Teen Pregnancy
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Access to Health Care
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Chronic Disease
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Other
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Contact Person:
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Address:
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| Street: |
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| City: |
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State:
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| Zip Code: |
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| Mailing Adress |
(if different from above):
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| Street: |
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| City: |
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State:
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| Zip Code: |
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| Phone Number: |
(
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Extension:
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| Fax Number: |
(
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-
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| Contact Email Adress: |
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Please describe your program in 150 words or less:
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| Funding Types: |
Fee-based
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Private
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Philanthropic
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Government
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Other
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| Is your program: |
For-profit
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Non-profit
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Faith-based
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Government Funded
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Other
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| Is there a fee for your program? |
Yes
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No
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Conditional
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Other
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| How often is this program provided? |
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Please list all areas served (cities, counties, etc):
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Target Audience for your program (please check all that
apply):
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Age:
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Pregnancy
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Infancy
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Preschool
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School Age
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Adolescent
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Adult
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Faith-based
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Other
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| Ethnicity: |
American Indian, Eskimo, Aleut
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Asian or Pacific Islander
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Black, Non-Hispanic
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Hispanic
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White, Non-Hispanic
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Other
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| Gender: |
Male
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Female
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| Income: |
Less than $15,000
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$15,000 - $30,000
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More than $30,000
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Other
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Web address(es) specific to your program:
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Please check if your organization can provide the following
to other agencies (for free or for a fee).
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For free (check all that apply):
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Staff
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Facilities
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Volunteers
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Training
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Presentations
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Consultation
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Financial Resources
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Other
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For a fee (check all that apply):
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Staff
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Facilities
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Volunteers
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Training
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Presentations
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Consultation
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Financial Resources
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Other
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What additional educational materials, websites, information,
or reproducible handouts do you have available?
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Other information about your program that you would
like to provide?
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