Cooking Matters for Kids
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1 Cking Matters fr Kids FY2017 Participant Survey Child s First Name 1. What is yur child s sex? Male Female 2. What is yur child s age? 7 and under and ver Is yur child Hispanic r Latin? Yes N 5. Have yu, yur child, r any ther members f yur husehld participated in any f the fllwing prgrams in the last year? (Mark all that apply.) WIC SNAP (frmerly Fd Stamps) Free r reduced-price schl breakfast Free r reduced-price schl lunch Free r reduced-price schl supper Free summer meals Head Start Fd Pantry Medicaid D nt participate in any f these prgrams. 4. What is yur child s race? (Yu may mark mre than ne.) White Black r African American Asian Native Hawaiian r Pacific Islander American Indian r Alaska Native Other (please specify) 6. Please list any fd allergies yur child has:
2 Befre Class Survey Please put an X in the bx t mark yur answer. Yur Name: 1. I can make smething t eat with fruit all by myself. YES! Definitely!!! Yes, I think I can d it. N, I dn t think I culd d it. NO! N way!!! Nt sure / I dn t knw what that is. 2. I can make smething with vegetables all by myself. YES! Definitely!!! Yes, I think I can d it. N, I dn t think I culd d it. NO! N way!!! Nt sure / I dn t knw what that is. 3. I can make healthy chices when I m ut t eat. YES! Definitely!!! Yes, I think I can d it. N, I dn t think I culd d it. NO! N way!!! Nt sure / I dn t knw what that is. 4. I can help make healthy chices at the grcery stre. YES! Definitely!!! Yes, I think I can d it. N, I dn t think I culd d it. NO! N way!!! Nt sure / I dn t knw what that is.
3 5. I can talk t my family abut healthy eating. YES! Definitely!!! Yes, I think I can d it. N, I dn t think I culd d it. NO! N way!!! Nt sure / I dn t knw what that is. 6. I can talk t my family abut healthy cking. YES! Definitely!!! Yes, I think I can d it. N, I dn t think I culd d it. NO! N way!!! Nt sure / I dn t knw what that is. 7. I can fllw recipe directins. YES! Definitely!!! Yes, I think I can d it. N, I dn t think I culd d it. NO! N way!!! Nt sure / I dn t knw what that is. 8. I can use a knife safely. YES! Definitely!!! Yes, I think I can d it. N, I dn t think I culd d it. NO! N way!!! Nt sure / I dn t knw what that is.
4 Please put an X in the bx t mark yur answer. 9. Hw d yu feel abut trying new fds? I really like t try new fds. I kind f like t try new fds. I dn t like t try new fds. I really dn t like t try new fds. I m nt sure if I like t try new fds. 10. Hw d yu feel abut eating fruit? I really like t eat fruit. I kind f like t eat fruit. I dn t like t eat fruit. I really dn t like t eat fruit. I m nt sure if I like t eat fruit. 11. Hw d yu feel abut eating vegetables? I really like t eat vegetables. I kind f like t eat vegetables. I dn t like t eat vegetables. I really dn t like t eat vegetables. I m nt sure if I like t eat vegetables.
5 12. Hw d yu feel abut eating whle grain fds, like whle wheat bread r trtillas, r whle grain crackers? I really like t eat whle grains. I kind f like t eat whle grains. I dn t like t eat whle grains. I really dn t like t eat whle grains. I m nt sure if I like t eat whle grains. 13. Hw d yu feel abut chsing drinks that are lw in sugar (such as plain, lw-fat milk and water)? I really like t chse drinks that are lw in sugar. I kind f like t chse drinks that are lw in sugar. I dn t like t chse drinks that are lw in sugar. I really dn t like t chse drinks that are lw in sugar. I m nt sure if I like t chse drinks that are lw in sugar.
6 After Class Survey Please put an X in the bx t mark yur answer. Yur Name: 1. I can make smething t eat with fruit all by myself. YES! Definitely!!! Yes, I think I can d it. N, I dn t think I culd d it. NO! N way!!! Nt sure / I dn t knw what that is. 2. I can make smething with vegetables all by myself. YES! Definitely!!! Yes, I think I can d it. N, I dn t think I culd d it. NO! N way!!! Nt sure / I dn t knw what that is. 3. I can make healthy chices when I m ut t eat. YES! Definitely!!! Yes, I think I can d it. N, I dn t think I culd d it. NO! N way!!! Nt sure / I dn t knw what that is. 4. I can help make healthy chices at the grcery stre. YES! Definitely!!! Yes, I think I can d it. N, I dn t think I culd d it. NO! N way!!! Nt sure / I dn t knw what that is.
7 5. I can talk t my family abut healthy eating. YES! Definitely!!! Yes, I think I can d it. N, I dn t think I culd d it. NO! N way!!! Nt sure / I dn t knw what that is. 6. I can talk t my family abut healthy cking. YES! Definitely!!! Yes, I think I can d it. N, I dn t think I culd d it. NO! N way!!! Nt sure / I dn t knw what that is. 7. I can fllw recipe directins. YES! Definitely!!! Yes, I think I can d it. N, I dn t think I culd d it. NO! N way!!! Nt sure / I dn t knw what that is. 8. I can use a knife safely. YES! Definitely!!! Yes, I think I can d it. N, I dn t think I culd d it. NO! N way!!! Nt sure / I dn t knw what that is.
8 Please put an X in the bx t mark yur answer. 9. Hw d yu feel abut trying new fds? I really like t try new fds. I kind f like t try new fds. I dn t like t try new fds. I really dn t like t try new fds. I m nt sure if I like t try new fds. 10. Hw d yu feel abut eating fruit? I really like t eat fruit. I kind f like t eat fruit. I dn t like t eat fruit. I really dn t like t eat fruit. I m nt sure if I like t eat fruit. 11. Hw d yu feel abut eating vegetables? I really like t eat vegetables. I kind f like t eat vegetables. I dn t like t eat vegetables. I really dn t like t eat vegetables. I m nt sure if I like t eat vegetables. 12. Hw d yu feel abut eating whle grain fds, like whle wheat bread r trtillas, r whle grain crackers? I really like t eat whle grains. I kind f like t eat whle grains. I dn t like t eat whle grains. I really dn t like t eat whle grains. I m nt sure if I like t eat whle grains.
9 13. Hw d yu feel abut chsing drinks that are lw in sugar (such as plain, lw-fat milk and water)? I really like t chse drinks that are lw in sugar. I kind f like t chse drinks that are lw in sugar. I dn t like t chse drinks that are lw in sugar. I really dn t like t chse drinks that are lw in sugar. I m nt sure if I like t chse drinks that are lw in sugar. 14. Did yu like cming t class? Yes N 15. What has been yur favrite part f this cking class? THANKS! FOR STAFF USE ONLY Check bxes fr each lessn the participant attended: Check which waivers the participant signed: Participatin/Infrmatin Media Mnth Curse Ended Partner Cde Curse Cde
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