Western Dairy Association

1. School/District Nutrition Director (*):
2. School Kitchen Manager (*):
3. Name of School (*):
4. Name of District (*):
5. Address of School (*):
6. City (*):
7. State (*):
8. Zip (*):

1. Fuel Up to Play 60 Program Advisor (*):
2. Phone (*):
3. Email (*):
4. Preferred Method of Contact (*): Email Phone

1. Grades to be served (*):
2. School Enrollment (*):
3. Current ADP Breakfast (*):
4. Percent free/reduced (*):
5. Average breakfast milk served (*):
6. Current ADP lunch (*):
7. Description of your current breakfast program:
8. What Expanded Breakfast option do you intend to offer? Breakfast in the classroom - breakfast served in the classroom Grab 'n' Go breakfast - meal carts / breakfast bags in high traffic areas Breakfast after first period - a healthy break after the day begins Breakfast on the bus - breakfast served on the bus ride to school Breakfast at the bell - breakfast served in entry of school Other - please describe below
9. Other breakfast option:
10. Expected percentage of participants in this Expanded Breakfast service (*):

1. Establish Mesurable Goals

   What goals do you intend to achieve?

2. Identify Target Audience

   What steps will you take to gain support from administrators, teachers, classified staff, parents and students?

3. Assess Strengths and Weaknesses

   Anticipated barriers/challenges to achieving objectives and strategies for overcoming them? (Barriers may include, but are not limited to: extra staffing requirements, tracking student participation, excess trash, increased need for storage of food and cooler for milk.)

   Barrier/Challenge	Strategy

4. Develop Expanding Breakfast Strategies

   How will you market or promote your new breakfast program to increase participation?

5. Line Item Budget

   Detail all expenses (equipment, promotion, other costs). Remember funds may not be used for food or labor.

   Expense	Quantity	Unit Cost	Total Cost
   Total Cost

6. Implementation Strategies

   Date	Strategy	What is Needed	Who is Responsible

7. Evaluation

   How will you evaluate your success? What information will you track? With what percentage increase of breakfast participation will you be satisfied?

   Please answer the above questions:

* Please note that the application deadline is December 1, 2010. Applicants are encouraged to submit the application as soon as possible for priority consideration. Program must be implemented during the 2010-2011 school year.