West Virginia Department of Education
Fresh Fruit & Vegetable Program
SCHOOL PROFILE FORM
SCHOOL INFORMATION:
*County
*School Name
*Address
Web Address
SCHOOL DATA:
*Enrollment as of October 2008
Grade Levels
Meals offered (check all that apply):
SBP
*Would you describe your school as (check one):
NSLP
Afterschool Snacks
Urban
Rural
Suburban
Percent (approximately) of student enrollment who are:
White:
American Indian
Alaskan Native
Hispanic
African American
Other Race/Ethnic Group
*Free/Reduced price meal data: (Percent NEEDY from October 2008)
Percent of children approved for free meals:
Team Nutrition School?
Yes
No
Percent reduced price meals:
*PROPOSAL:
How Often: (# of days per week):
Serving Time of Day:
Equipment Needed:
Serving Places:
Persons In Charge Of:
Prep
Purchase
Serving
Record Keeping
Identify partnerships your school may have or develop to support the program (Examples may include, PTA or PTO,
vendors, Partners in Ed, School Wellness Councils, Dairy Council, Junior Master Gardeners).
Describe how you plan to incorporate the Fresh Fruit & Vegetable Program into the school schedule. Explain briefly how
this program will benefit your students and why your school should be chosen. Use school data or other unique aspects
such as special curriculum projects, or programs. Discuss how you might integrate this program with other efforts to
promote sound health and nutrition, address childhood obesity or promote physical activity.
Identify possible barriers or problems and how you will overcome:
STAFFING INFORMATION:
Contact Person:
Name:
Phone Number(s):
Position
Phone Number 1
Fax Number
Phone Number 2
E-Mail Address:
SIGNATURES (ALL ARE REQUIRED)
We have reviewed this application and attest to the information provided. If selected, we agree to
implement the program as outlined above and to implement the project in a manner consistent
with the policies and procedures established by USDA. Further, we agree to participate in any
USDA-sponsored evaluations and to provide the information requested by the specified
deadlines.
(Please provided the contacts shown below or equivalent positions as determined by the school).
*County Nutrition Director (signature)
*Date
*Print Name
*Title
*Phone Number
*Fax Number
*Email Address
*School Principal Signature
Date
*Cafe Manager Signature
Date
*County Superintendent Signature
Date
* Required Data Element
MAIL COMPLETED FOR TO:
ATT: Becky Leigh, WVDE
Office of Child Nutrtion
Building 6, Room 248; 1900 Kan. Blvd., East
Charleston, WV 25305-9969
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