ࡱ> #` bjbj\.\. 0>D>D $%a::::J9J9J989;Ju<8ND"pDpDpDSG:OLS(!t#t#t#t#t#t#t$FwhyGtVF^SGVVGt::pDpDuaaaVv:8pDpD!taV!taanhropD < BQJ9wVn-qu0JunRz}W: Rz oRzolVVaVVVVVGtGt`^VVVJuVVVVd!)):::::: African American Churches Eating Smart and Moving More: Planning & Resource Guide Request Form Thank you for your interest in the African American Churches Eating Smart and Moving More (AACESMM) Planning and Resource Guide. In an effort to monitor the Guide's usefulness and effectiveness, please complete this Guide Request Form. The questions on this form will enable the AACESMM planning team to collect demographic information on all recipients of the Guide along with their responses to questions concerning the church/organization that they are working or planning to work with. All of your responses will be kept in a confidential database and your contact information will only be shared/used to provide you with information or to connect others in your community with whom you may want to work. Please identify ALL the churches in question #8 if you are working or planning to work with more than one church below. Completing and Returning this Form If you received this form via e-mail or from a website... Please type your answers in the gray areas. Use the tab key or mouse to move the cursor from one gray area to the next. When done, please save your completed form and send it back via e-mail (as an attachment) to  HYPERLINK "mailto:nc5aday@ncmail.net" nc5aday@ncmail.net. You can also fax this form to 919-870-4804. If you received a hard copy of this form at a workshop or have printed a copy to complete by hand Please PRINT (with black ink) your answers below. When done return this form to: Diane Beth, MS, RD, LDN, Nutrition Coordinator, Physical Activity & Nutrition Branch, NC Division of Public Health, 1915 Mail Service Center, Raleigh, NC 27699-1915. You can also fax this form to 919-870-4804. For questions on how to fill out the form, please call (919) 707-5228.  Your Contact Information Name  FORMTEXT        FORMTEXT       Address ( the address where you would like us to ship materials) FORMTEXT       City, State, Zip code  FORMTEXT        FORMTEXT        FORMTEXT       Preferred Phone Number (XXX) XXX-XXXX  FORMTEXT       Preferred Fax Number (XXX) XXX-XXXX  FORMTEXT       Preferred Email Address  FORMTEXT       County (for address listed above)  FORMTEXT       Today's Date FORMTEXT        Personal Information What is your race? (Please select one)  FORMCHECKBOX  African-American  FORMCHECKBOX Asian American  FORMCHECKBOX  American Indian  FORMCHECKBOX  Other Minority  FORMCHECKBOX  White  FORMCHECKBOX Other 2. What is your gender?  FORMCHECKBOX Male  FORMCHECKBOX Female Please select the statement below that BEST describes your current status  FORMCHECKBOX Community health professional currently working with an African-American church.  FORMCHECKBOX Community health professional planning to work with an African-American church.  FORMCHECKBOX Community health professional not working with/planning to work with an African-American church.  FORMCHECKBOX Church member working with a community health professional on health in an African-American church.  FORMCHECKBOX Church member planning to work with a community health professional on health in an African-American church.  FORMCHECKBOX Church member not working with/planning to work with a community health professional on health in an African-American church.  FORMCHECKBOX Other  FORMTEXT       (please write in) If you are a community health professional, which organization do you work for?  FORMCHECKBOX Healthy Carolinians  FORMCHECKBOX Health Department  FORMCHECKBOX Cooperative Extension  FORMCHECKBOX Other  FORMTEXT       (write in) Are you currently working with a church?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If you are NOT working with a church, are you planning to work with a church or churches in the near future?  FORMCHECKBOX Yes  FORMCHECKBOX No  FORMCHECKBOX Not sure If you are NOT working with a church and not planning to work with a church, how will the AACESMM Guide be used?  FORMCHECKBOX Dissemination to other community organizations  FORMCHECKBOX Join with other churches to implement components of the Guide  FORMCHECKBOX Use the Guide as a personal resource  FORMCHECKBOX Use the Guide to provide trainings (please complete the Guide workshop training information on the last page of this form)  FORMCHECKBOX Other  FORMTEXT       (please write in) If you are working with a church and would like to request a Guide for the church(s), please provide the following information for each of the churches/faith organizations that you are working with (either as a church member yourself or as an outside partner organization. (Use additional sheets of paper or add rows to this table if needed.) Name of Church and Person to ContactMailing Address including City, State, ZipCountyDoes the Church have a health Ministry or Health Program?Are you currently working with that health ministry or health program? FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT      Yes FORMCHECKBOX  No FORMCHECKBOX  Don't Know FORMCHECKBOX Yes FORMCHECKBOX  No FORMCHECKBOX  FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT       Yes FORMCHECKBOX  No FORMCHECKBOX  Don't Know FORMCHECKBOX Yes FORMCHECKBOX  No FORMCHECKBOX  FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT      Yes FORMCHECKBOX  No FORMCHECKBOX  Don't Know FORMCHECKBOX Yes FORMCHECKBOX  No FORMCHECKBOX  FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT      Yes FORMCHECKBOX  No FORMCHECKBOX  Don't Know FORMCHECKBOX Yes FORMCHECKBOX  No FORMCHECKBOX  FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT      Yes FORMCHECKBOX  No FORMCHECKBOX  Don't Know FORMCHECKBOX Yes FORMCHECKBOX  No FORMCHECKBOX  FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT      Yes FORMCHECKBOX  No FORMCHECKBOX  Don't Know FORMCHECKBOX Yes FORMCHECKBOX  No FORMCHECKBOX  FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT      Yes FORMCHECKB`ae> L P , - 1 2 A D a ²“scVcscF7hUhbCJOJQJaJhUhb5CJOJQJaJhY"f5CJOJQJaJhUhGB5CJOJQJaJhUh\5CJOJQJaJhUhw'5CJOJQJaJhUh\CJOJQJaJhUhGB6CJOJQJaJhUhga!6CJOJQJaJhUhGBCJOJQJaJhUhw'CJOJQJaJh"hGBCJOJQJaJh"hGB5CJOJQJaJ8`a, -  L 8968h^hgdGBgdGB & FgdJ & FgdJ & FgdJgdJgdR gdw'`gdGB$a$gdGB"     L $7>?ͦ}n^Nn;%jh"hP:CJOJQJUaJh"hGB>*CJOJQJaJh"hY>*CJOJQJaJh"hGBCJOJQJaJ0jh"hGBCJOJQJUaJmHnHuhUhJ>*CJOJQJaJ hUhJ0JCJOJQJaJ+jhUhJCJOJQJUaJ%jhUhJCJOJQJUaJhUhJCJOJQJaJhUhJ5CJOJQJaJ?IJ  $&(248ȯȠw^O@h"hYCJOJQJaJh"hGBCJOJQJaJ0jh"hw'CJOJQJUaJmHnHu+jCh"hl%CJOJQJUaJ%jh"hw'CJOJQJUaJh"hw'CJOJQJaJ0jh"hP:CJOJQJUaJmHnHu%jh"hP:CJOJQJUaJ+jh"hga!CJOJQJUaJh"hP:CJOJQJaJ$&:<>HJLNbdfֽ֮ցkֽ\I\3I+jh"hl%CJOJQJUaJ%jh"hw'CJOJQJUaJh"hw'CJOJQJaJ+j/h"hga!CJOJQJUaJh"hP:CJOJQJaJh"hYCJOJQJaJh"hGBCJOJQJaJh"h5YCJOJQJaJ0jh"hP:CJOJQJUaJmHnHu%jh"hP:CJOJQJUaJ+jh"hga!CJOJQJUaJ8o./gdGB `gdGB `gdGB hx^hgdGB & F&^&gdGBxgd"gdw'h^hgdGBgdGBgd5Yfprtv\^rtvůԠ~hO9+jh"hw'CJOJQJUaJ0jh"hP:CJOJQJUaJmHnHu+jh"hga!CJOJQJUaJh"hP:CJOJQJaJ%jh"hP:CJOJQJUaJh"hGBCJOJQJaJ+jh"hl%CJOJQJUaJh"hw'CJOJQJaJ%jh"hw'CJOJQJUaJ0jh"hw'CJOJQJUaJmHnHuv"$&:<>HJhj~Ŷ~eYCe+jh"hga!CJOJQJUaJhY"fCJOJQJaJ0jh"hP:CJOJQJUaJmHnHu+j{h"hga!CJOJQJUaJh"hP:CJOJQJaJ%jh"hP:CJOJQJUaJh"hGBCJOJQJaJh"hw'CJOJQJaJ%jh"hw'CJOJQJUaJ0jh"hw'CJOJQJUaJmHnHu~  -.<ֽ֮vcT>ccT+jh"hl%CJOJQJUaJh"hw'CJOJQJaJ%jh"hw'CJOJQJUaJh"hDCJOJQJaJh"hGB>*CJOJQJaJ0jh"hGBCJOJQJUaJmHnHuh"hGBCJOJQJaJ0jh"hP:CJOJQJUaJmHnHu%jh"hP:CJOJQJUaJ+jch"hga!CJOJQJUaJ<=>MN\]^op~ָָ}ǸǸָgǸǸָQ+jh"hl%CJOJQJUaJ+jh"hl%CJOJQJUaJh"hDCJOJQJaJ+j3h"hl%CJOJQJUaJ+jh"hl%CJOJQJUaJh"hw'CJOJQJaJh"hGBCJOJQJaJ%jh"hw'CJOJQJUaJ+jKh"hl%CJOJQJUaJ%&'./VZyz<=Kݢ츓mW+j h"hl%CJOJQJUaJ+jw h"hl%CJOJQJUaJh"hGB5CJOJQJaJh"hsnCJOJQJaJ+j h"hl%CJOJQJUaJh"hGBCJOJQJaJ+jh"hl%CJOJQJUaJh"hw'CJOJQJaJ%jh"hw'CJOJQJUaJ/y<$flgdGBgdsn & F&x^&gdGBxgdGBgdUhhx^h`hgdGB & F&h^&gdGBB<^`BgdGBBx^`BgdGB & FgdGBKLM$%345fhָָָvָ`M%jh"hP:CJOJQJUaJ+j9 h"hl%CJOJQJUaJ+j h"hl%CJOJQJUaJ+jM h"hl%CJOJQJUaJ+j h"hl%CJOJQJUaJh"hw'CJOJQJaJh"hGBCJOJQJaJ%jh"hw'CJOJQJUaJ+ja h"hl%CJOJQJUaJ <ȯȠr\rFr+j h"hl%CJOJQJUaJ+j% h"hl%CJOJQJUaJh"hw'CJOJQJaJ%jh"hw'CJOJQJUaJhUCJOJQJaJh"hGBCJOJQJaJ0jh"hP:CJOJQJUaJmHnHu%jh"hP:CJOJQJUaJ+j h"hga!CJOJQJUaJh"hP:CJOJQJaJ<>@lrt68Tǻtt^Et0jh"hw'CJOJQJUaJmHnHu+jh"hl%CJOJQJUaJh"hw'CJOJQJaJ+jh"hUCJOJQJUaJh"hUCJOJQJaJ%jh"hUCJOJQJUaJhUCJOJQJaJh"hGBCJOJQJaJ%jh"hw'CJOJQJUaJ+jh"hl%CJOJQJUaJTVXbdfh78FGHMN\]^fguvwǻ֬dž֬p֬Z֬D+jMh"hl%CJOJQJUaJ+jh"hl%CJOJQJUaJ+jah"hl%CJOJQJUaJh"hGB5CJOJQJaJ+jh"hl%CJOJQJUaJh"hw'CJOJQJaJhnCJOJQJaJh"hGBCJOJQJaJ%jh"hw'CJOJQJUaJ+juh"hl%CJOJQJUaJw45CDE(V񾯙񾯃mWHh"h~CJOJQJaJ+j%h"hl%CJOJQJUaJ+jh"hl%CJOJQJUaJ+j9h"hl%CJOJQJUaJ+jh"hl%CJOJQJUaJh"hw'CJOJQJaJ%jh"hw'CJOJQJUaJh"hGB5CJOJQJaJhKHhGB>*CJ OJQJaJ h"hGBCJOJQJaJ4   !/!6!p!!$IfgdGBlgd> & F hgd>*^*gdGBx^`gd5"L 8x^8gdGB & FgdGBV ô֋|fM>h"h>CJOJQJaJ0jh"hP:CJOJQJUaJmHnHu+jh"hga!CJOJQJUaJh"hP:CJOJQJaJ%jh"hP:CJOJQJUaJ+jh"hl%CJOJQJUaJh"hw'CJOJQJaJ%jh"hw'CJOJQJUaJh"hGBCJOJQJaJh5"LCJOJQJaJh"hgCJOJQJaJL   L !!!!!" " """߱iPAh"hw'CJOJQJaJ0jh"hP:CJOJQJUaJmHnHu+j.h"hga!CJOJQJUaJh"hP:CJOJQJaJ%jh"hP:CJOJQJUaJh"hGB5CJOJQJaJh"hGBCJOJQJaJh"hgCJOJQJaJh"h>5CJOJQJaJh"h>CJOJQJaJ"h"h>5>*CJOJQJaJ!!""8"`"b"H55555$IfgdGBlkd$$Ifl4rbdl"'  t0r'44 laytn""&"("*"4"6"8":"N"P"R"\"^"`"b"d"x"z"|"""ݛv]N8+jh"hl%CJOJQJUaJh"hGBCJOJQJaJ0jh"hP:CJOJQJUaJmHnHu+jh"hga!CJOJQJUaJh"hP:CJOJQJaJ%jh"hP:CJOJQJUaJ0jh"hw'CJOJQJUaJmHnHu+jh"hl%CJOJQJUaJh"hw'CJOJQJaJ%jh"hw'CJOJQJUaJb"""""#.#f#### h$IfgdGBl$Ifgdql$IfgdGBl """""""""""""""""###ޯw^O9+jh"hl%CJOJQJUaJh"hGBCJOJQJaJ0jh"hP:CJOJQJUaJmHnHu+jh"hga!CJOJQJUaJh"hP:CJOJQJaJ%jh"hP:CJOJQJUaJ0jh"hw'CJOJQJUaJmHnHu+j h"hl%CJOJQJUaJ%jh"hw'CJOJQJUaJh"hw'CJOJQJaJ## # #(#*#,#.#B#D#`#b#d#l#n##############~hUFh"hP:CJOJQJaJ%jh"hP:CJOJQJUaJ+jh"hl%CJOJQJUaJ+jZh"hl%CJOJQJUaJ+jh"hl%CJOJQJUaJ+jnh"hl%CJOJQJUaJh"hw'CJOJQJaJ%jh"hw'CJOJQJUaJh"hGBCJOJQJaJh"hga!CJOJQJaJ####$6$8$H55555$IfgdGBlkdF$$Iflrbdl"'  t0r'44 laytn##########$ $ $$$$$&$($2$4$6$8$ֽ֮v]N8ֽ֮+jh"hga!CJOJQJUaJh"hP:CJOJQJaJ0jh"hw'CJOJQJUaJmHnHu+jdh"hl%CJOJQJUaJ%jh"hw'CJOJQJUaJh"hw'CJOJQJaJh"hGBCJOJQJaJ0jh"hP:CJOJQJUaJmHnHu%jh"hP:CJOJQJUaJ+jh"hga!CJOJQJUaJ8$:$N$P$R$\$^$b$d$x$z$|$$$$$$$$$$$ݘ݅v`G8h"hGBCJOJQJaJ0jh"hP:CJOJQJUaJmHnHu+jBh"hga!CJOJQJUaJh"hP:CJOJQJaJ%jh"hP:CJOJQJUaJ+jh"hl%CJOJQJUaJ0jh"hw'CJOJQJUaJmHnHu+jRh"hl%CJOJQJUaJh"hw'CJOJQJaJ%jh"hw'CJOJQJUaJ8$`$b$$$$$%>%h%j%% h$IfgdGBl$Ifgdga!l$IfgdGBl $$$$$$$$$$%%%%%%8%:%<%D%F%b%d%f%h%j%n%p%%%%%ϪϪ~hϪR+jh"hl%CJOJQJUaJ+jh"hl%CJOJQJUaJ+jh"hl%CJOJQJUaJ+j.h"hl%CJOJQJUaJh"hga!CJOJQJaJ+jh"hl%CJOJQJUaJ%jh"hw'CJOJQJUaJh"hGBCJOJQJaJh"hw'CJOJQJaJ%%%%%&&J77777$IfgdGBlkd $$Iflrbdl"'  t0r'44 laytn%%%%%%%%%%%%%%%%%%%& & &쟐}g}N}8+j!h"hga!CJOJQJUaJ0jh"hw'CJOJQJUaJmHnHu+j !h"hl%CJOJQJUaJ%jh"hw'CJOJQJUaJh"hw'CJOJQJaJh"hGBCJOJQJaJ0jh"hP:CJOJQJUaJmHnHu+j h"hga!CJOJQJUaJh"hP:CJOJQJaJ%jh"hP:CJOJQJUaJ &&&&&&(&*&4&6&:&<&P&R&T&^&`&b&d&x&z&|&&&ϠϠwhRw9w0jh"hP:CJOJQJUaJmHnHu+j"h"hga!CJOJQJUaJh"hP:CJOJQJaJ%jh"hP:CJOJQJUaJ+j"h"hl%CJOJQJUaJ0jh"hw'CJOJQJUaJmHnHu+j"h"hl%CJOJQJUaJ%jh"hw'CJOJQJUaJh"hw'CJOJQJaJh"hGBCJOJQJaJ&8&:&b&&&&'>'@'h' h$IfgdGBl$Ifgdql$IfgdGBl &&&&&&&&&&&&&&&'''''8':'<'>'@'D'F'b'd'f'j'Ϲުϔު~hR+jL%h"hl%CJOJQJUaJ+j$h"hl%CJOJQJUaJ+j`$h"hl%CJOJQJUaJ+j#h"hl%CJOJQJUaJh"hga!CJOJQJaJ+jt#h"hl%CJOJQJUaJh"hw'CJOJQJaJ%jh"hw'CJOJQJUaJh"hGBCJOJQJaJh'j''''''J77777$IfgdGBlkd%$$Iflrbdl"'  t0r'44 laytnj'l'''''''''''''''''''''쟐}g}N}8+jT'h"hga!CJOJQJUaJ0jh"hw'CJOJQJUaJmHnHu+j&h"hl%CJOJQJUaJ%jh"hw'CJOJQJUaJh"hw'CJOJQJaJh"hGBCJOJQJaJ0jh"hP:CJOJQJUaJmHnHu+jf&h"hga!CJOJQJUaJh"hP:CJOJQJaJ%jh"hP:CJOJQJUaJ''''''( ( (((&(((*(4(6(8(:(N(P(R(\(^(ϠϠwhRw9w0jh"hP:CJOJQJUaJmHnHu+j(h"hga!CJOJQJUaJh"hP:CJOJQJaJ%jh"hP:CJOJQJUaJ+jB(h"hl%CJOJQJUaJ0jh"hw'CJOJQJUaJmHnHu+j'h"hl%CJOJQJUaJ%jh"hw'CJOJQJUaJh"hw'CJOJQJaJh"hGBCJOJQJaJ'((8(`(((())>) h$IfgdGBl$Ifgdql$IfgdGBl ^(f(h(((((((((((((((((())))))8):)<)@)Ϲުϔު~hުR+j+h"hl%CJOJQJUaJ+j*h"hl%CJOJQJUaJ+j*h"hl%CJOJQJUaJ+j)h"hl%CJOJQJUaJh"hga!CJOJQJaJ+j0)h"hl%CJOJQJUaJh"hw'CJOJQJaJ%jh"hw'CJOJQJUaJh"hGBCJOJQJaJ>)@)h)j))))J77777$IfgdGBlkd~+$$Iflrbdl"'  t0r'44 laytn@)B)V)X)Z)d)f)h)j)l)))))))))))))쟐}g}N}8+j-h"hga!CJOJQJUaJ0jh"hw'CJOJQJUaJmHnHu+j,h"hl%CJOJQJUaJ%jh"hw'CJOJQJUaJh"hw'CJOJQJaJh"hGBCJOJQJaJ0jh"hP:CJOJQJUaJmHnHu+j",h"hga!CJOJQJUaJh"hP:CJOJQJaJ%jh"hP:CJOJQJUaJ)))))))))))))* * ***$*&*(*2*4*ϠϠwhRw9w0jh"hP:CJOJQJUaJmHnHu+jv.h"hga!CJOJQJUaJh"hP:CJOJQJaJ%jh"hP:CJOJQJUaJ+j-h"hl%CJOJQJUaJ0jh"hw'CJOJQJUaJmHnHu+j-h"hl%CJOJQJUaJ%jh"hw'CJOJQJUaJh"hw'CJOJQJaJh"hGBCJOJQJaJ)))*6*`*****+ h$IfgdGBl$Ifgdw'l$IfgdGBl 4*<*>*Z*\*^*`*d*f*******************++++Ϲުϔ~hR+j0h"hl%CJOJQJUaJ+jN0h"hl%CJOJQJUaJ+j/h"hl%CJOJQJUaJ+jb/h"hl%CJOJQJUaJh"hga!CJOJQJaJ+j.h"hl%CJOJQJUaJh"hw'CJOJQJaJ%jh"hw'CJOJQJUaJh"hGBCJOJQJaJ++>+@+h+++J77777$IfgdGBlkd:1$$Iflrbdl"'  t0r'44 laytn++,+.+0+:+<+>+@+B+V+X+Z+d+f+h+j+~+++++쟐}g}N}8+j2h"hga!CJOJQJUaJ0jh"hw'CJOJQJUaJmHnHu+jT2h"hl%CJOJQJUaJ%jh"hw'CJOJQJUaJh"hw'CJOJQJaJh"hGBCJOJQJaJ0jh"hP:CJOJQJUaJmHnHu+j1h"hga!CJOJQJUaJh"hP:CJOJQJaJ%jh"hP:CJOJQJUaJ+++++++++++++++++++++, ,ϠϠwhRw9w0jh"hP:CJOJQJUaJmHnHu+j24h"hga!CJOJQJUaJh"hP:CJOJQJaJ%jh"hP:CJOJQJUaJ+j3h"hl%CJOJQJUaJ0jh"hw'CJOJQJUaJmHnHu+jB3h"hl%CJOJQJUaJ%jh"hw'CJOJQJUaJh"hw'CJOJQJaJh"hGBCJOJQJaJ++++ ,6,^,,,,, h$IfgdGBl$Ifgdql$IfgdGBl ,,,0,2,4,6,:,<,X,Z,\,^,r,t,,,,,,,,,,,,,,,,,Ϲުϔު~hުR+j6h"hl%CJOJQJUaJ+j 6h"hl%CJOJQJUaJ+j5h"hl%CJOJQJUaJ+j5h"hl%CJOJQJUaJh"hga!CJOJQJaJ+j4h"hl%CJOJQJUaJh"hw'CJOJQJaJ%jh"hw'CJOJQJUaJh"hGBCJOJQJaJ,,-->-f-h-H55555$IfgdGBlkd6$$Iflrbdl"'  t0r'44 laytn,,--------,-.-0-:-<->-@-T-V-X-b-d-쟐}g}N}8+j8h"hga!CJOJQJUaJ0jh"hw'CJOJQJUaJmHnHu+j8h"hl%CJOJQJUaJ%jh"hw'CJOJQJUaJh"hw'CJOJQJaJh"hGBCJOJQJaJ0jh"hP:CJOJQJUaJmHnHu+j7h"hga!CJOJQJUaJh"hP:CJOJQJaJ%jh"hP:CJOJQJUaJd-f-h-j-~-------------------ϠϠwhRw9w0jh"hP:CJOJQJUaJmHnHu+j9h"hga!CJOJQJUaJh"hP:CJOJQJaJ%jh"hP:CJOJQJUaJ+jz9h"hl%CJOJQJUaJ0jh"hw'CJOJQJUaJmHnHu+j9h"hl%CJOJQJUaJ%jh"hw'CJOJQJUaJh"hw'CJOJQJaJh"hGBCJOJQJaJh-----6KL` h$IfgdGBl$Ifgdql$IfgdGBl ---. $%3459:HIJLNO]^_aϷިϒި|fިP+j@<h"hl%CJOJQJUaJ+j;h"hl%CJOJQJUaJ+jT;h"hl%CJOJQJUaJ+j:h"hl%CJOJQJUaJh"hga!CJOJQJaJ+jh:h"hl%CJOJQJUaJUh"hw'CJOJQJaJ%jh"hw'CJOJQJUaJh"hGBCJOJQJaJOX  No FORMCHECKBOX  Don't Know FORMCHECKBOX Yes FORMCHECKBOX  No FORMCHECKBOX Note: We would like to collect more detailed information on each of the churches you are or will be working with and will be sending a follow-up survey. This information will be used for evaluating the AACESMM initiative. Would you like to receive a list of individuals in your area who are using or planning to use the Guide with their church/organization?  FORMCHECKBOX Yes  FORMCHECKBOX No Are you willing to let us list you as a possible resource/contact person for other churches/organizations in your area that are using or planning to use the Guide?  FORMCHECKBOX Yes  FORMCHECKBOX No Would you like to occasionally receive resources via email to promote healthy eating, physical activity and/or health ministries in churches? If yes, please be sure to provide an accurate email address on page 1.  FORMCHECKBOX Yes  FORMCHECKBOX No If you are not planning to conduct a workshop in the near future using the Guide, you are finished with this form. If you are planning a workshop, please complete the additional form on the last page. Please be sure that churches you are planning to train on the Guide are listed in question #8 above. Please refer to page 1 for where to return this form. Thanks again for your interest in the African American Churches Eating Smart and Moving More Guide. Guide Workshop Training Information Please complete this form when you are planning to conduct a workshop using the AACESMM Guide and will need more copies of the Guide for the workshop participants. Please send in this form at least 30 days prior to your workshop to allow time for packaging and mailing. (*Please indicate if information is the same as indicated on page 1 of the Guide Request form.) Workshop Date  FORMTEXT      Number of anticipated registrants FORMTEXT      Number of anticipated churches represented at the training FORMTEXT      Number of Guides needed FORMTEXT      Workshop Location  FORMTEXT      Person(s) conducting Workshop  FORMTEXT      Organization Name  FORMTEXT      *Mailing Address (Large boxes must be shipped to street address; not PO Box number)  FORMTEXT      *City, State, Zip  FORMTEXT        FORMTEXT        FORMTEXT      *Ph`aAB HA:, & F h@xgdGB<gdGBxgdbkd<$$Ifl)rbdl"'  t0r'44 laytnaA̡ۡ͡ܡݡDSŢƢǢУѣߣ;;;p;Z;+j>h"hl%CJOJQJUaJ+jJ>h"hl%CJOJQJUaJhY"fCJOJQJaJ+j=h"hl%CJOJQJUaJ+j^=h"hl%CJOJQJUaJh"hw'CJOJQJaJ%jh"hw'CJOJQJUaJh"hGBCJOJQJaJh"hb5CJOJQJaJ @AwxܥrsxgdGB $xa$gdGBxgdY"f $xa$gdgxgdgx&d P gdGB & FgdGB h@xgdY"f & F h@xgdGB h@^gdsnߣ '@AwxܥָǒucucuSuSCh{hg5CJOJQJaJhY"fhg5CJOJQJaJ"hY"fhg5>*CJOJQJaJhY"fhg5CJOJQJaJh{5CJOJQJaJh"hGB5CJOJQJaJ+j?h"hl%CJOJQJUaJh"hw'CJOJQJaJh"hGBCJOJQJaJ%jh"hw'CJOJQJUaJ+j6?h"hl%CJOJQJUaJܥݥЦ5joqsϿϝ}mVD1%jh"hga!CJOJQJUaJ#h"hGB0J>*CJOJQJaJ,h"hGB0J>*B*CJOJQJaJphh"h~5CJOJQJaJh"h"5CJOJQJaJh"hL5CJOJQJaJh"h|5CJOJQJaJ"h)Kh?$5>*CJOJQJaJh)Kh?$5CJOJQJaJh)Kh 5CJOJQJaJh"hGB5CJOJQJaJh"hb5CJOJQJaJsT|:}kd@$$Ifl06$0r t0644 laytGB$Ifgd~l$($Ifa$gd{l$($If^a$gdGBl TVjlnxz|~ȳȤ|fȳȤR;,h"h{0J>*B*CJOJQJaJph&h{0J>*B*CJOJQJaJph+j2Ah"hga!CJOJQJUaJ,h"hGB0J>*B*CJOJQJaJph h"hGB0JCJOJQJaJh"hGBCJOJQJaJ)jh"hga!CJOJPJQJUaJ%jh"hga!CJOJQJUaJ+j"@h"hga!CJOJQJUaJh"hga!CJOJQJaJ|~cP$Ifgd~l$($If^a$gdGBlkdA$$Ifl06$0r t0644 laytGB NPdfhrtvݡwhRw=w.h"hGBCJOJQJaJ)jh"hga!CJOJPJQJUaJ+jZCh"hga!CJOJQJUaJh"hga!CJOJQJaJ%jh"hga!CJOJQJUaJ,h"hGB0J>*B*CJOJQJaJph h"h{0JCJOJQJaJ)jh"h{CJOJPJQJUaJ+jFBh"h{CJOJQJUaJh"h{CJOJQJaJ%jh"h{CJOJQJUaJNvcP$Ifgd~l$($If^a$gdGBlkdB$$Ifl06$0r t0644 laytGBvxƩcK8$Ifgd~l$($Ifa$gd{l$($If^a$gdGBlkdC$$Iflp06$0r t0644 layt{vx©ĩƩȩ "$.024XŶŋ|hQŶ;ŋ|+j~Eh"hga!CJOJQJUaJ,h"h{0J>*B*CJOJQJaJph&hGB0J>*B*CJOJQJaJphh"hGBCJOJQJaJ)jh"hga!CJOJPJQJUaJ+jnDh"hga!CJOJQJUaJh"hga!CJOJQJaJ%jh"hga!CJOJQJUaJ,h"hGB0J>*B*CJOJQJaJph h"hGB0JCJOJQJaJƩȩ 2eMM:$Ifgd~l$($Ifa$gd{l$($If^a$gdGBl}kdD$$Ifl06$0r t0644 laytGB24XZ\eMM:$Ifgd~l$($Ifa$gd{l$($If^a$gdGBl}kdE$$Ifl06$0r t0644 laytGBXZ\^rtv02F³ˆyhQ:³,h"hGB0J>*B*CJOJQJaJph,h"hL0J>*B*CJOJQJaJph h"hGB0JCJOJQJaJh"hGBCJOJQJaJ)jh"hga!CJOJPJQJUaJ+jFh"hga!CJOJQJUaJh"hga!CJOJQJaJ%jh"hga!CJOJQJUaJ,h"h{0J>*B*CJOJQJaJph&hGB0J>*B*CJOJQJaJph.0XccP$Ifgd~l$($If^a$gdGBlkdG$$Ifl06$0r t0644 layt FHJTVXZ\ֲs`Q;`&`(jh"hCJUaJmHnHu+jHh"hxCJOJQJUaJh"hCJOJQJaJ%jh"hCJOJQJUaJ,h"hGB0J>*B*CJOJQJaJph,h"hL0J>*B*CJOJQJaJph h"hGB0JCJOJQJaJh"hGBCJOJQJaJ)jh"hga!CJOJPJQJUaJ%jh"hga!CJOJQJUaJ+jGh"hga!CJOJQJUaJXZ~eM:$Ifgd~l$($Ifa$gd{l$($If^a$gdGBl}kdH$$Ifl06$0r t0644 laytGB«̫ΫЫҫ޳޳ގ}fOMO:%jh"hga!CJOJQJUaJU,h"hGB0J>*B*CJOJQJaJph,h"hL0J>*B*CJOJQJaJph h"hGB0JCJOJQJaJh"hGBCJOJQJaJ+jIh"hxCJOJQJUaJ(jh"hCJUaJmHnHu+j*Ih"hxCJOJQJUaJ%jh"hCJOJQJUaJh"hCJOJQJaJ@cK8$Ifgd~l$($Ifa$gd{l$($If^a$gdGBlkdJ$$IflF06$0r t0644 laytGBone Number  FORMTEXT      *E-mail Address  FORMTEXT           PAGE  PAGE 4 For office use only: Reference Code: _________________ Date form received: ___________ .02<>@BDdfz|~ȳȤ|eOȳȤA6hh CJaJjhkCUmHnHu+jKh"hga!CJOJQJUaJ,h"hGB0J>*B*CJOJQJaJph,h"hL0J>*B*CJOJQJaJph h"hGB0JCJOJQJaJh"hGBCJOJQJaJ)jh"hga!CJOJPJQJUaJ%jh"hga!CJOJQJUaJ+jJh"hga!CJOJQJUaJh"hga!CJOJQJaJ@BbdcK8$Ifgd~l$($Ifa$gd{l$($If^a$gdGBlkd.K$$IflC06$0r t0644 layt xvvvvvvvvjh &`#$gdGBxgdkCkdBL$$Ifl06$0r t0644 layt  "\ÿÿýùhFKh Uh hkCh h&0JmHnHuhY hY0JjhY0JUh1jh1UhkCh CJaJ  "LxgdkCxgdFKxgd $*3&#$a$gdkC Received via _____fax _____email ______mail Date Guide(s) is/are shipped _______________________________ Date form data entered in database______________________ .:pGB/ =!"#$% DyK nc5aday@ncmail.netyK 4mailto:nc5aday@ncmail.nettDText1xDText112tDText2tDText3xDText113xDText114tDText4tDText4tDText5tDText6tDText7tDeCheck1tDeCheck2tDeCheck3tDeCheck4tDeCheck5tDeCheck6tDeCheck7tDeCheck8tDeCheck9vDeCheck10vDeCheck11vDeCheck12vDeCheck13vDeCheck14vDeCheck15vDText23vDeCheck16vDeCheck17vDeCheck18vDeCheck19xDText115vDeCheck20vDeCheck21vDeCheck22vDeCheck23vDeCheck24vDeCheck25vDeCheck26vDeCheck27vDeCheck28vDeCheck29vDText38$$If!vh55 555#v#v #v#v#v:Vl4 tr'55 555ytnvDText41xDText116vDText40xDText123xDText124vDText42vDeCheck37vDeCheck38vDeCheck39vDeCheck40vDeCheck41$$If!vh55 555#v#v #v#v#v:Vl tr'55 555ytnvDText43xDText117vDText44xDText125xDText126vDText45vDeCheck42vDeCheck43vDeCheck44vDeCheck45vDeCheck46$$If!vh55 555#v#v #v#v#v:Vl tr'55 555ytnvDText46xDText118vDText51xDText127xDText128vDText56vDeCheck47vDeCheck48vDeCheck49vDeCheck50vDeCheck51$$If!vh55 555#v#v #v#v#v:Vl tr'55 555ytnvDText47xDText119vDText52xDText129xDText130vDText57vDeCheck52vDeCheck53vDeCheck54vDeCheck55vDeCheck56$$If!vh55 555#v#v #v#v#v:Vl tr'55 555ytnvDText48xDText120vDText53xDText131xDText132vDText58vDeCheck57vDeCheck58vDeCheck59vDeCheck60vDeCheck61$$If!vh55 555#v#v #v#v#v:Vl tr'55 555ytnvDText49xDText121vDText54xDText133xDText134vDText59vDeCheck62vDeCheck36vDeCheck35vDeCheck63vDeCheck64$$If!vh55 555#v#v #v#v#v:Vl tr'55 555ytnvDText50xDText122vDText55xDText135xDText136vDText60vDeCheck30vDeCheck31vDeCheck32vDeCheck33vDeCheck34$$If!vh55 555#v#v #v#v#v:Vl) tr'55 555ytnvDeCheck65vDeCheck66vDeCheck67vDeCheck68vDeCheck69vDeCheck70xDText102$$If!vh505r#v0#vr:Vl t06505rytGBxDText103$$If!vh505r#v0#vr:Vl t06505rytGBxDText103$$If!vh505r#v0#vr:Vl t06505rytGBxDText104$$If!vh505r#v0#vr:Vlp t06505ryt{xDText105$$If!vh505r#v0#vr:Vl t06505rytGBxDText106$$If!vh505r#v0#vr:Vl t06505rytGBxDText107$$If!vh505r#v0#vr:Vl t06505ryt xDText108$$If!vh505r#v0#vr:Vl t06505rytGBxDText137xDText138xDText139$$If!vh505r#v0#vr:VlF t06505rytGBxDText110$$If!vh505r#v0#vr:VlC t06505ryt xDText111$$If!vh505r#v0#vr:Vl t06505ryt H@H TSNormal hOJQJ_HmH sH tH F@F GB Heading 3$$@&a$ CJOJQJDA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List 4 @4 GBFooter  !0U@0 GB Hyperlink>*B*r@r GB Table Grid7:V0  h@.)@!. GB Page Number6@26 kCHeader h!`% `c%9gT * z & o ~ >%@0@0@0@0@0@0@0@ 0@0@0@0@0@0@ 0@0@ 0 @0@0 @00"8`a,-L89fgTU  * Q 0 y z & o ~ >()=Oz,@AUVj~+,@AUij,-AUj~,@Ui+@Tp+?[pq*F[\pqQR PQ "!!!!!!!!!!"-"."F"Z"["m"n"""""""""""""6#7#K#L#^#_########### $ $$$$$$$$ $!$"$-$.$/$0$$$3%%%%0@0@0@0@00@0@0 0 0 0 0 0 0 0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@00@0@0 0000@0 00@0@0@0@00@0 0@00@0 0@0 0@0@0 0@0@0@000@0 0@0@0@0 @0 @0 @0 @0 @0 @0@0@0 @0@0@0@0@0 @0 00@0 @0@0@0 @0 @0@0@0 @0@0@0@0@0 @0@0 00@0 @0@0@0 @0 @0@0@0 @0@0@0@0@0 @0 00@0 @0@0@0 @0 @0@0@0 @0@0@0@0@0 @0 00@0 @0@0@0 @0 @0@0@0 @0@0@0@0@0 @0 00@0 @0@0@0 @0 @0@0@0 @0@0@0@0@0 @0 00@0 @0@0@0 @0 @0@0@0 @0@0@0@0@0 @0 00@0 @0@0@0 @0 0@0 0@0 00 0@000@0@0@0@00@0@0@0@0@0@0 @0 @0 @0 @0 @0 0)0)0 0 @0 @0 @0@0 @0 @0 @0@0@0 @0 @0 @0@0@0 @0 @0 @0@0 @0 @0 @0@0 @0 @0 @0@0 @0 @0 @0@0 @0 @0 0@0h00@0h00@0h00@0h00@0@0@0@0@0@0h000@0@0@0@0 8`a,-L89fgTU  * Q 0 y z & o ~ >(Ozpq!!!!!!!Z"["m"n"""""""""""6#7#K#L#^#_########### $ $-$%@0@0@0@0@0@0@0@0@ 0A 0A 0@ 0A 0A 0@ 0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@ 0@0@0@0@0@ 0@0@0@0@0@0@0@0@ 0@0@0@0@ 0@0@ 0@0@0@ 0@0@0@0@0@0@0@ 00 00 00 00 00 0 @00 00 @0 004@0004@0004@0004@000 00 004@0 @0@0@0@0@0@0@00K0(L7@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0 00$@0@0 00$ $$$' ?fv~<K<TwV""##8$$% &&j''^(@))4*++ ,,d--aߣܥvXF !"$%&'(*+-/023578:<=?ABDFGIKLNWYZ\^adfhkn8/!b"#8$%&h''>))++,h-` s|vƩ2X@#),.1469;>@CEHJMVX[]_`bcegilmo >JPR^d@LRy  T d x  ( J Z a q & 6 o  ~ 7GZj>N$*,8>AMSVbhjv|#),8>AMSUagm}$*-9?AMSXhl|$*,8>CSWgs#).>BR^ns)-=IY^ns(4DIY^n !!!!!!"%"+"F"R"X"n"z""""""""7#C#I#_#k#q#s############%XFFFFFFFFFFFG$G$G$G$G$G$G$G$G$G$G$G$G$G$G$FG$G$G$G$FG$G$G$G$G$G$G$G$G$G$FFFFFFFG$G$G$G$G$FFFFFFG$G$G$G$G$FFFFFFG$G$G$G$G$FFFFFFG$G$G$G$G$FFFFFFG$G$G$G$G$FFFFFFG$G$G$G$G$FFFFFFG$G$G$G$G$G$G$G$G$G$G$FFFFFFFFFFFFF  '!!l  ,R$*bU $ oq@ (  B  s XDo.B  s XDo.N   3   B S  ? #%  y=S"TText1Text112Text2Text3Text113Text114Text4Text5Text6Text7Check1Check2Check3Check4Check5Check6Check7Check8Check9Check10Check11Check12Check13Check14Check15Text23Check16Check17Check18Check19Text115Check20Check21Check22Check23Check24Check25Check26Check27Check28Check29Text38Text41Text116Text40Text123Text124Text42Check37Check38Check39Check40Check41Text43Text117Text44Text125Text126Text45Check42Check43Check44Check45Check46Text46Text118Text51Text127Text128Text56Check47Check48Check49Check50Check51Text47Text119Text52Text129Text130Text57Check52Check53Check54Check55Check56Text48Text120Text53Text131Text132Text58Check57Check58Check59Check60Check61Text49Text121Text54Text133Text134Text59Check62Check36Check35Check63Check64Text50Text122Text55Text135Text136Text60Check30Check31Check32Check33Check34Check65Check66Check67Check68Check69Check70Text102Text103Text104Text105Text106Text107Text108Text137Text138Text139Text110Text111>Sg@T x  J a & o ~ 0Z>-BWk-BVm.BXl-CWs.B^s-I^s4I^ !!G"o"""8#`#t####%  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~QeS e ) [ r 7 HkO+?Ti}*?Th~+@Ti}+?Th*?So*>Zo)EZo!!Y""""J#r#####% $ $ $ $$$$$$$$$$"$,$/$0$%%#ot % 7 m | $ $ $ $$$$$$$$$$"$,$/$0$f$m$%%333333333333AD$<<>QReg@S     > O T e x    ) 0 0 J [ ` ` a r y y & 7 o ~ 0HZk>Oggrrv())+,?ATVij}*,?ATUhm~+-@ATXil}+,?CTWhs*.?BS^os*->IZ^os)4EIZ^oqqPQRRTc  !!#!$!d!e!l!z!!!!!!!!."F"Y"m"m"n""""""""""""7#J#L#M#^#^#_################# $ $ $ $ $$$$$$$$$$"$,$0$%%%%% $ $ $ $$$$$$$$$/$0$%jl DI:!SީrS]I1\ u|ȎUzwΠw**^*`o(.h ^`o(hH. L^`LhH.   ^ `hH. jj^j`hH. :L:^:`LhH.   ^ `hH. ^`hH. L^`LhH.h^`OJQJo(hHh ^`o(hH.hpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hHh ^`o(hH.hpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh **^*`hH.^`o(.h pLp^p`LhH.h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.h^`OJQJo(hHh ^`o(hH.hpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hH1\ ujrS]UzwI:!(x                           Jo                UTbsnpNR .j~qWY| ga!"t %w*}*^K-)/rV59r:GB?iCDKH5"LCsL#8U5Y[\)#]A_4eY"fq!g3hnt?uU})KNw l%R ><'}x>$f "w'\;LTS{P:FK,a#! &g?$c%CUJ kCL1V(dg)Oz,j~UjAU,@+p[FpqQe!!!!!!!!"-"."F"Z"["n"""""""""7#K#L#_########## $0$g$%%I1A(I1I1I1@KP@~ KKKKK K KKKK!"#$%P@PPP(@PPP8@PP@@P"P@@PPPP@UnknownGz Times New Roman5Symbol3& z Arial9GaramondI& ??Arial Unicode MSE&Berlin Sans FB;Wingdings?5 z Courier New"1hzznzaAaAY4d## 2QKX ?27African American Churches Eating Smart and Moving More:DPHDPH      Oh+'0H T`    8African American Churches Eating Smart and Moving More:DPH0AACESMM Guide Request form 2.14.07 final.dotDPH2Microsoft Office Word@@Q@:aQ@:aQa՜.+,D՜.+,l( hp   DPH / DHHSA# 8African American Churches Eating Smart and Moving More: Title 8@ _PID_HLINKSAlimailto:nc5aday@ncmail.net  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqstuvwxyz{|}~Root Entry FpKQData rL1TablerzWordDocument0SummaryInformation(DocumentSummaryInformation8CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q