Instructions for Filling out The

Instructions for Filling Out the

FNP Client Enrollment Form

Nutrition Educator: Nutrition Educator’s full Age of Children: Just the ages of the children name (names are optional and only for your records)

Client Name: Client’s first and last name Other Adults in Household: Do NOT include client, roommates or other adults in facility Entry Date: Date of first meeting with client Ethnicity: Choose from drop-down menu Client e-mail: Clients accurate email address (for future contact or appointment reminders) Race: Choose from drop-down menu

Local Address: Street address where Public Assistance: Check corresponding box(es) curriculum is being presented of forms of assistance they are currently receiving City: City where curriculum is being presented EXIT Information: To be filled out regardless of State: State where curriculum is being client’s status presented Exit date: Date client, or NE, finished final Zip: Zip code where curriculum is being paperwork presented Number of Lessons: Number of curriculum Group Affiliation: Name of group NE is working lessons taught with (if applicable) Number of contacts: Number of times NE has Program/Delivery Site: Location where met with client to provide nutrition education curriculum is being presented (i.e. rehab center, (if one lesson is taught over multiple days, then home, etc.) record one contact for each day)

Enrolled in ANEP/EFNEP Before: Check yes or Multiple check-boxes: Check box that best no describes client’s status at the time of final paperwork. Client may be contacted post-program: Check yes or no Graduation Certificate: Is a graduation Certificate requested? Check box if yes, leave Age: Age of client upon entry into program blank if no Gender: Gender of client (male or female) PAGE 2 Pregnant: Is client pregnant or possibly Client Name: Re-enter client name pregnant, check yes or no Date/Lesson Topic/Duration: Date, lesson and Is client nursing: Check yes or no minutes the presentation lasted. Highest grade: Highest grade achieved/passed, Notes: Enter any notes relevant to client, choose from drop-down menu location, presentation, etc. Household income: Monthly income from all If you have any questions, please call: sources (907)474-6339