UMBER OF STUDENTS BY CLASSROOM · Enter the number of students for each classroom the teacher or extender will be using SNAP-Ed Curriculum with. For example: A Pre-school teacher

_____________________________________ ______________________________________

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County

CalFresh Healthy Living, University of California

Nutrition, Gardening and Physical Activity Enrollment Form

EXTENDER ENROLLMENT FORM

Name ________________________________________________________________________

Site/School Name and Address ____________________________________________________

Email ________________________________ Phone __________________________________

NUMBER OF STUDENTS BY CLASSROOMFor teachers teaching multiple classes or groups of children like PE or Pre-K, please complete one row for each class or group of students taught, otherwise only complete line 1 for a single classroom.

Line Classroom(s) Number of children age 0-4 Number of children age 5-17

1. Classroom or Group 1








SNAP-ED CURRICULUM

Please choose all primary and additional curriculum that apply

Enter Primary Curricula in Blue box

I, the educator and undersigned, commit to:

Use the UC CalFresh SNAP-Ed curriculum to deliver nutrition education.

Complete the Program Activity Reporting Form

Teacher/Extender Signature Date

This material was funded by USDA's Supplemental Nutrition Program - SNAP, known in California as CalFresh. These institutions are equal opportunity providers and employers. CalFresh provides assistance to low-income households and can help buy nutritious foods for better health. For CalFresh information, call 1-877-847-3663. Document1 Revised 8/5/2019 2:00 PM

This material was funded by USDA's Supplemental Nutrition Program - SNAP, known in California as CalFresh. These institutions are equal opportunity providers and employers. CalFresh provides assistance to low-income households and can help buy nutritious foods for better health. For CalFresh information, call 1-877-847-3663. C:\Users\mammajq\AppData\Local\Box\Box for Office\304202619\Temp\jvkrpvfn.osw\Enrollment2020.docx Revised 8/5/2019 3:33 PM

Extender Enrollment Form Purpose:

The purpose of this form is to gather teacher or extender (youth or adult) information for use while entering data into the PEARS System.

Please have each teacher or extender complete this form once during the fiscal year for each site they are working at.

Enter the number of students for each classroom the teacher or extender will be using SNAP-Ed Curriculum with. For example:

A Pre-school teacher with an AM and a PM group of children will complete two (2) lines for two groups of students


1. Classroom or Group 1 25

2. Classroom or Group 2 25

Similarly a PE teacher may complete 5 separate groups of classes that they are teaching a PA curricula with.


1. Classroom or Group 1 20 2. Classroom or Group 2 22 3. Classroom or Group 3 23 4. Classroom or Group 4 21 5. Classroom or Group 5 25

For sites that are not part of a public school please collect demographic information as follows either from the teacher or based on a visual estimate of the classroom or site as a whole.

Demographics Students Number of Male students

Number of Female students Ethnicity

Number of Hispanic students Number of Not Hispanic students

Race Number of American Indian students

Number of Asian students Number of Black students

Number of Hawaiian / Pac. Isl. students Number of White students

Distributing the forms for data collection: 1. Download the form and save to your computer from the UC CalFresh Website

a. Forms can be found under the PEARS Tab in Program Activities

2. Open Adobe

3. Using the toolbar in Adobe, click on “View” and choose “Tracker” from the dropdown menu

4. Click on the “Forms” and choose “Distribute”

5. This will start a setup wizard to distribute your form

a. Locate the form you wish to distribute by clicking on Browse and click “next”

6. Choose to collect responses via email

Distributing Forms in Adobe Revised: 8/6/19 Page-1

7. Send using Adobe Acrobat

8. Enter email address for your extenders/teachers and click send

9. Extenders will receive the form and be able to complete and submit this form back to you when finished

10. Responses will come back to the email box of the sender or distributer of the form

11. When you double click the attached file it will open up the tracker tool again to help you keep track ofyour responses

a. This tool gives you the ability to filter by a specific field like the site name, export, add otherforms collected and archive forms in one place.

b. The Export will go into a CSV or comma delimitated file that can be opened in Excel.

From Received Date

Federal Fiscal Year County Name

Site/Scho ol Name and

Address Email Phone

Number of children age 04Classro om or Group 1

Number of

children age 517Classr oom or Group 1


Number of



Number of



Number of


Number of children age

04Classro om or Group 5

Number of children age 517Classr oom or Group 5







Number of

children age 04Classro om or Group 8


Primary Curriculu m

Additiona l

Curriculu m3

Enrollme nt Form_dist ributed2

(002).pdf jq 8/6/2019 11:24 2020 ALAMEDA Jen ABC Elem 5th Street

jaquigley @ucdavis .edu

555‐555‐

5555 0 25 0 0 0 0 0 0 0 0 0 0 0 0 0

CATCH/3‐

5: Activity Box

Go Glow Grow

Distributing Forms in Adobe Revised: 8/6/19 Page-2

Documents

UMBER OF STUDENTS BY CLASSROOM · Enter the number of students for each classroom the teacher or extender will be using SNAP-Ed Curriculum with. For example: A Pre-school teacher