Center for Weight and Health

Program and Resource Information
Reporting Form

The Center for Weight and Health is interested in learning about and disseminating information about organizations, programs, projects and resources concerning weight, nutrition, physical activity and/or food security. If you are involved with such an organization, project, program or resource that you would like to tell us about, please complete this form as fully as possible. If you want to tell us about something that is pending or being planned for the near future, we would also like you to return this questionnaire with as much information as you can provide along with the anticipated start date.

Please take a few moments to tell us about your program. When you are finished, click the "Submit" button at the bottom of the form to send the information to us. If you have trouble, please contact Eve Donovan at (510) 642-2915 or edonovan@nature.berkeley.edu. Thank you for your assistance.

I. About the Program or Organization:

Program or organization name:
Brief description of mission, goals, objectives and/or activities:
Contact person:
Contact person's title:
Address:
City:
State:
ZIP:
Phone:
Fax:
Organization Email address:
Web site address:	http://
Date program began (or anticipated to begin):
Would you like us to include a description of this program/ organization on our website?	Yes No
Would you like us to include a link to your web site from ours?	Yes No

How would you best categorize the organization?
Community-based Organization
Schools
Government
Religious (e.g. Jewish Federation)
Non-profit (e.g. United Way, Boys & Girls Club, etc.)
Other:

II. About the Materials, Tools, or Other Resources:

Name of resource:
Resource Description:
Target audience, including age:
Cost of materials:
Contact person:
Contact person's title:
Phone:
Fax:
E-mail:
Address:
City:
State:
Zip:
Web site address:	http://

 

III. About You:

Your name:
Your title:
Phone:
Fax:
E-mail:
Address:
City:
State:
ZIP:
Web site address:	http://

To submit this form, please enter the characters you see in the image:
	Why?
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You Are Finished!

Thanks again for sharing this information with us!

Click "Submit" to send us your reply, or "Reset" to clear all of the fields and start over.