Body Walk Program

Food Power Adventure 2014-2015 School Schedule Request Form

Region: Select Region Date: Extension Contact Person for this site: Phone #’s: Office: Cell: Home:

Date(s) Food Power Adventure: Start Date: End Date:

School Information: Name of Host School: County:

School Street Address: City: Zip Code:

School's Main Phone No: Fax No:

School Contact Information: School Coordinator Name: (The person at the school responsible for organizing Food Power) School Coordinator’s Position/Title: School Coordinator’s Phone Numbers*: School: Home: OR Cell: School Coordinator’s email address: *Home or cell numbers are requested in the event of inclement weather or unforeseen schedule changes

Name of building if exhibit will be set up at a location other than school above: Address for this location:

Names of other schools participating Food Power Adventure at this school (if applicable):

Total number of students participating in Food Power for the above date(s):

Billing Information: Name of school or organization to be billed the $100 exhibit fee, if different from School Information above: School or organization contact name: email address*: Fax No: Phone No: *email is the preferred method for billing payer

PLEASE RETURN COMPLETED FORMS TO CINDY DEBLAUW

Form Completion Instructions  Complete the form for each school scheduled for Food Power in the 2014-15 school year. Use the “arrow keys” or mouse to move to each completion field (the grey shaded boxes)  Send completed forms to Cindy DeBlauw via email [email protected] (preferred method), Fax 573/884-5412 or 1205 University Ave, Suite 300, Columbia MO 65211

Upon receipt of the completed form: o The information will be entered on the appropriate East or West Food Power master calendar which is posted in the Outlook Shared Public Folders. o An invoice will be sent (preferred method is email) to the appropriate school/organization and payment will be tracked in a database. o Once the invoice is paid a confirmation will be sent to the host school.

D:\Docs\2018-04-04\0d9d979bb2a6d9fb315190b2579691a3.doc