Name of Student _____________________________ Grade ___

Happy Feet, Healthy Food Kids’ Club Pre-Club Survey

Please help us gather data so that we may assess the value and effectiveness of our club.

1. Please circle the following fruits that you believe your child would eat for snack or lunch on occasion.

Apples Oranges Grapes Bananas Strawberries Watermelon Cantaloupe Kiwi

2. Please circle the following vegetables that you believe your child would eat for snack or lunch.

Lettuce Carrots Peppers Broccoli Cucumbers Green beans Celery Sweet potatoes

3. Will your child eat whole-grain bread? Yes or No

4. Do you and your child look for the word “whole” on food packages (cereal and other)? Yes or No

5. Do you buy low- or non-fat dairy products for your children over the age of two? Yes or No

5. Do you exercise with your child? Yes or No

6. Does your child exercise after school? Yes or No

7. Does one or more parent exercise on a regular basis? Yes or No

8. Please list your child’s favorite fruit and vegetable on the back (only 1 each, please). Add other comments to the back of this page. Return to Mrs. Goodrow A.S.A.P.

THE “OFFICIAL HAPPY FEET, HEALTHY FOOD KID” CLUB RIBBON

Club ribbons will be earned by completing a 10-week Happy Feet chart at club. Children will fill in various symbols for competing certain tasks which include: running/walking laps, bringing healthy snacks to club, eating Happy Feet lunches at school or home, journaling at home, and eating healthy snacks at home.

YOUR CHILD WILL EARN A “FREE” COLOR-IN SYMBOL TOWARD HIS/HER RIBBON BY RETURNING THIS COMPLETED SURVEY TO CLUB.