Registration Healthcare Montana Harvest of the Month Healthcare RegistrationInstructions The Montana Harvest of the Month program is open to Healthcare Institutions in Montana. Please coordinate with your Harvest of the Month team at your organization to avoid duplicate registrations. One packet will be provided for each participating healthcare program site. For example, a food service management company that is registering three hospitals and one skilled nursing facility can receive four packets. Additional posters are available for purchase at Montana State University Extension's publication store. Materials will be mailed to the address in this registration form (please use an institution's address, not a personal address). A team is crucial for a successful implementation of the Harvest of the Month program and creates valuable connections within the institution and community. If you have not approached all the required members of your Harvest of the Month team (administrator, food service, and dietitian/clinical staff) you may still register. Please be in touch with your team members as soon as possible. Anyone listed as a team member with contact information will receive monthly email Harvest of the Month updates. This will help remind your team of available resources and updates. You can register multiple institutional program sites at the same time with this form. You will list each of the participating sites. This registration form collects one set of team members. If you wish to have different team members listed for each site, please complete a separate registration form per site. These individual institution/program teams might have overlapping team members such as food service staff or administrator.If you have questions, please contact: Molly Kirkham Montana Local Food Program Specialist National Center for Appropriate Technologymollyk@ncat.org (406) 494-8672 Facility InformationFirst Name *Primary ContactLast Name *Primary ContactInstitution Name *Position of Affiliation *Email *Primary Phone *Address 1 *The materials should be mailed to an organization or business, not a home address. Please no PO Boxes.Address 2 City *County *Zip/Postal Code * Harvest of the Month DetailsWhich type best describes your facility? *Skilled Nursing FacilityAssisted Living FacilityLong-Term Care FacilityCritical Access HospitalGeneral HospitalSpecialized HospitalOtherList Participating Healthcare Institutions Below, individually list all institutions that are participating within this registration. You will receive one packet per site listed below. Only include institutions that will be participating in the Harvest of the Month program. Is this new to your organization and you do not have all of the components or team members ready to go? No problem! Assemble your team, make a plan, and let us help you build a successful Harvest of the Month program at your institution. You are welcome to register even if your site is still working out the details.Participating Site 1 *Participating Site 2 Participating Site 3 Participating Site 4 Participating Site 5 Participating Site 6 Site Expectations *Serve the Harvest of the Month item in at least one meal or a la carte offering during the month.Conduct at least one educational/promotional activity regarding the Harvest of the Month item each month.Use the Harvest of the Month materials and display visible locations.Participate in evaluations.Attend an online (archived or live) or in-person training (highly recommended)By registering your team is pledging to all the expectations listed above. Please check all boxes. If your site struggles with any of these expectations our team is here to help! Remember, starting small and conducting quick activities such as reading the item's fun facts each month in a staff meeting is a great start!Abundant MT Directory *YesNoAll HOM sites will be listed on the Abundant Montana directory, hosted by the Alternative Energy Resources Organization (AERO). To help food producers and businesses connect with your program, we wish to include your contact information. Do you agree to have contact information listed on this map? Team Members If you have not approached all the required members of your Harvest of the Month team you may still register. Any team members listed will receive HOM communications.AdministratorName Email Food Service Director or ProfessionalName Email Dietitian or Clinical Staff MemberName Email Additional Team Members List any additional team members here. We encourage you to include others on your team such as staff, community organizations, SNAP-ed educators, Extension Agents, etc. These individuals are often very helpful in conducting taste tests and educational activities or can help promote your program. Any team members listed will receive HOM communications. You can add or update team members through your portal profile.Name Position/title Email Name Position/title Email Name Position/title Email HOM Healthcare Portal CredentialsUsername *UsernamePassword *PasswordMembership Level * Healthcare Verification Please enter any two digits with no spaces (Example: 12)* This box is for spam protection - please leave it blank:
