Mosaic School Nutrition Challenge Application Form

Applications are due March 31st.
All strategies must be able to be operational by September to be eligible for a cash award.
Please ensure that ALL questions are answered.
Incomplete or late applications will not be considered
GENERAL INFORMATION
School Name*
School Division or First Nation Educational Authority (do not use acronym)*
Type of School*
- Elementary
- Middle
- Secondary/High School
- K-12
Is your school on a First Nations Reserve?*
- Yes
- No
If yes, please identify name of reserve (do not use acronym)
School Address*
Street Address PO Box (if applicable) City/Town Province/Territory Postal Code
Total Number of Students*
Total Number of Staff*
Principal Information*
Salutation First Name Last Name Phone
Email*
Section 1: CONCEPT
DESCRIBE IMPROVEMENT PLAN
Research clearly links access to proper nutrition to better academic outcomes, physical & mental health and well-being.
In a few sentences, briefly describe the school plan to IMPROVE student nutrition:*
In a few sentences, briefly describe how the plan is an IMPROVEMENT over what currently exists:*
Briefly describe what makes this project unique from other similar projects? What stands out?*
Does the improvement plan include a renovation project?*
- Yes
- No
If yes, please specify:
(IE: build a teaching station within existing kitchen)
Does the improvement plan include the purchase of new equipment?*
- Yes
- No
If yes, please specify:
(IE: industrial cooler, commercial dishwasher, tower garden etc.)
Section 2: Nutrition
Please provide the following details about your school nutrition program(s). Breakfast and lunch are defined as meals that provide a minimum of 3 of 4 food groups and snacks provide a minimum of 2 of the 4 food groups.
Breakfast (served before or during class)*
Average number of students fed each day Number of days program will operate each week Is this or will this be a new program for your school?
Lunch*
Average number of students fed each day Number of days program will operate each week Is this or will this be a new program for your school?
Snack (morning)*
Average number of students fed each day Number of days program will operate each week Is this or will this be a new program for your school?
Snack (afternoon)*
Average number of students fed each day Number of days program will operate each week Is this or will this be a new program for your school?
How many months in the academic year will your program operate?*
Will students have increased access to nutritious foods while at school because of the Plan?*
- Yes
- No
If yes, will access to nutritious foods be:
- Daily
- Weekly
- Monthly
- Less than once per month
Briefly describe how the Plan seeks to improve student nutrition:*
Does the school have a food policy?*
- Yes
- No
Will the school implement food policy because of the Plan?*
- Yes
- No
Does the Plan include formal nutrition education for students?*
(IE: instructional time/cooking classes/workshops etc.)
- Yes
- No
If yes, briefly describe the formal instruction:
(IE: How many students will receive this instruction? How many hours of formal instruction will each student receive? Who will provide this instruction? What will the participants learn/how will this be assessed?)
Does the Plan include formal nutrition education for parents/caregivers?*
(IE: cooking classes/workshops etc.)
- Yes
- No
If yes, briefly describe the formal instruction:
(IE: How many parents will receive formal instruction? How many hours will each parent/caregiver receive? Who will provide this instruction/what will the participants learn/how will this be assessed?)
Does the Plan include training/certification for students?*
- Yes
- No
If yes, briefly describe the type of training/certification the students will receive:
How many students will receive this training/certification?
Does the Plan include training/certification for parents/caregivers?*
- Yes
- No
If yes, briefly describe the type of training/certification the parents/caregivers will receive:
How many parents/caregivers will receive this training/certification?
Section 3: CULTURE
Project Committee Information:*
List participants who will contribute to your improvement plans by title (IE: Principal, teacher, parent, student, town/band council member, dietitian, health care professional, nutritionist, RCMP, community volunteer) and provide a brief sentence on the role of each member with respect to the proposed Makeover (IE: Dietitian will teach 2 workshops on proper nutrition/Grade 3 Teacher will implement afterschool cooking class /town or band council member will liaise between the school and community to secure additional funds for project). Click the "+" above to add more rows.
Briefly describe how the improvement plan addresses and/or improves the cultural environment: (Inclusive, equitable, community &/or school wide involvement, inclusive of community, culture of learning):*
Briefly describe how the Plan addresses Reconciliation:*
The Mosaic School Nutrition Challenge provides an opportunity to engage in Reconciliation. All communities benefit when we support the Calls to Action in the Final Report of the Truth and Reconciliation Commission (TRC). Judges will prioritize those plans that evidence authentic engagement and show commitment to the philosophy "nothing about us, without us".
Will the program(s) (if applicable) be universally offered regardless of participants’ ability to pay?*
- Yes
- No
If no, how will you accommodate students who are unable to pay?
Section 4: IMPACT
Briefly describe the desired OUTCOME(s) of the Plan and how it seeks to improve overall health outcomes:*
Briefly describe the STRATEGIES you will implement to achieve the desired outcome(s) noted above:*
A. PERCEIVED BENEFIT: Briefly describe the Plan’s potential to positively impact students, staff, parents and the community at large (who will be impacted and how will they be impacted? Be specific):*
B. NEED: Please identify the role a Mosaic cash award would have on the implementation of this improvement plan:*
Section 5: PLANNING
If the proposed Plan includes a renovation component, has the division approved this project?
- Yes
- No
If the proposed Plan includes the purchase of new equipment, has the division approved installation of this equipment?
- Yes
- No
In two or three sentences, describe how is the proposed improvement plan is sustainable:*
(IE: what is your plan to keep the program operating after Mosaic School Nutrition Challenge cash award is spent?)
Is the school Plan dependent in whole or in part on receiving a cash award?*
- Yes
- No
Please provide information about the revenue and expenses for the school nutrition improvement plan (include all program(s)/project(s) listed in Section 2 of this application).
Please ESTIMATE the total revenue for your improvement plan in each of the following areas (enter zero if not applicable).
Federal
(i.e. Indigenous & Northern Affairs Canada, Agriculture & Agri-Food Canada, etc.)
Provincial
(i.e. Ministry support {Education/Health/Social Services})
Municipal/Local
(i.e. Community Association, School Board)
Parent/Advisory Council/School Fundraisers
Businesses/Corporations
Charitable Organizations
(i.e Rotary/Kiwanis, Boys and Girls Club etc.)
In Kind Contributions
Other Revenue
Please specify
Mosaic School Nutrition Challenge Award (if selected)
(This amount MUST equal $20,000)
TOTAL REVENUE*
(sum of all revenue amounts listed above - budget must not reflect zero revenue)
Please estimate your total costs for your improvement plan in each of the following areas (enter zero if not applicable).
Equipment
Food
Appliances
(fridge, dishwasher, oven, freezer, etc.)
Supplies
(i.e. napkins, cutlery, bins)
Other Expense (1)
Please specify
Other Expense (2)
Please specify
Other Expense (3)
Please specify
TOTAL EXPENSES*
(sum of all revenue amounts listed above)
TOTAL REVENUE MINUS TOTAL EXPENSES*
Mosaic Cash Award of $20,000 is automatically added to income portion of budget.
The box below must balance at zero or show a deficit in order to be considered.
I have ensured the box above balances at zero or shows a deficit*
(the Submit button will not show below unless you have confirmed this)
- Yes, the box balances at zero or shows a deficit
AGREEMENT AND SUBMISSION
Schools that receive a cash award agree that their names and related information about their program may be shared for these purposes: to assess applications, provide donor stewardship and to promote mission based activities. By submitting this application, the school principal/senior administrator who is the site authority agrees to abide by Terms and Conditions listed below:
The principal confirms the information provided in this application is accurate and that the school:
• Will complete and submit an Impact Report on the funding provided by January 31st
• Will recognize donor on social media and/or school/division website (s) and other mediums as applicable
• Will submit a short video clip, photos and quotes highlighting their project and its impact for use in the Mosaic Showcase and other public communications shared by the Saskatchewan School Boards Association (SSBA) and The Mosaic Company
• Will ensure all participant permissions/releases are obtained for use of the video, photos and quotes by SSBA and The Mosaic Company for the stated purposes.
• Grants permission to the Saskatchewan School Boards Association and The Mosaic Company to use the contents of this application for reporting purposes and to release information as noted in the application
I have read and agree to the Terms and Conditions*
- Yes
Name of Site Authority*
Date*
Date Format: MM slash DD slash YYYY
I am ready to submit this application*
(click "Yes, I am ready to submit" to show the Submit button)
- Yes, I am ready to submit