SNACK Program Referral
Please use this form to submit a referral request for the SNACK Program's nutrition services. Services are available to all kids 6-18 in Yamhill County. A good referral could be someone with: 1) a score of 5 or high on the Nutrition Assessment attached below; 2) a desire to make changes to eating habits or a desire for behavior change support; 3) a risk for a diet related disease; 4) a behavioral health issue impacted by diet; 5) an interest in learning about the foundations of nutrition and building healthy habits. Questions? Email director@snackprogram.org
Parent/Caregiver Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Language
*
English
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Child's Name
*
First Name
Last Name
Child Date of Birth
*
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Month
-
Day
Year
Date
Child's Name
First Name
Last Name
Child Date of Birth
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Month
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Day
Year
Date
Child's Name
First Name
Last Name
Child Date of Birth
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Month
-
Day
Year
Date
Nutrition Assessment for Children
Completed Nutrition Assessment
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Referring Email
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