Register for Family Kitchen at Home

As part of the programme we ask families to fill in pre and post questionnaires on diet and eating behaviour.
This information is used to evaluate the impact of the programme.
All personal data provided throughout the programme will be kept no longer than 18 months and will be destroyed securely.

1. Family Details: *

Full Name:	*
Address:	*
Postcode:	*
Mobile:	*
Email:	*
1st Child's Name:	*
1st Child's Date of Birth:	*
2nd Child's Name:
2nd Child's Date of Birth:
3rd Child's Name:
3rd Child's Date of Birth:
Do you have more children:

2. Please Note: One portion of fruit or vegetables (excluding potatoes) is equal to the amount that fits on the palm of YOUR hand *


a. How many portions of fruit do you eat on an average day?	a. How many portions of fruit do you eat on an average day?
b. How many portions of vegetables do you eat on an average day?	b. How many portions of vegetables do you eat on an average day?

3. One portion of FRUIT is equal to the amount of fruit that fits on the palm of your child/rens hand *


a. How many portions of fruit does your 1st child eat on an average day?	a. How many portions of fruit does your 1st child eat on an average day?
b. How many portions of fruit does your 2nd child eat on an average day?	b. How many portions of fruit does your 2nd child eat on an average day?
c. How many portions of fruit does your 3rd child eat on an average day?	c. How many portions of fruit does your 3rd child eat on an average day?

4. One portion of VEGETABLES (excluding potatoes) is equal to the amount that fits on the palm of your child/rens hand *


a. How many portions of vegetables does your 1st child eat on an average day?	a. How many portions of vegetables does your 1st child eat on an average day?
b. How many portions of vegetables does your 2nd child eat on an average day?	b. How many portions of vegetables does your 2nd child eat on an average day?
c. How many portions of vegetables does your 3rd child eat on an average day?	c. How many portions of vegetables does your 3rd child eat on an average day?

5. Cooking together: *


How confident do you feel about cooking with your child/ren?	How confident do you feel about cooking with your child/ren?

6. Eating together as a family: *


How many times a week do you eat together with your child/ren?	How many times a week do you eat together with your child/ren?

7. Families for Life Child Eating Behaviour Questionnaire:
Please read the following statements and tick the boxes most appropriate for your 1st Child’s eating behaviour. *

	Never	Rarely	Sometimes	Often	Always
My child refuses new foods at first	My child refuses new foods at first Never	My child refuses new foods at first Rarely	My child refuses new foods at first Sometimes	My child refuses new foods at first Often	My child refuses new foods at first Always
My child enjoys tasting new foods	My child enjoys tasting new foods Never	My child enjoys tasting new foods Rarely	My child enjoys tasting new foods Sometimes	My child enjoys tasting new foods Often	My child enjoys tasting new foods Always
My child enjoys a wide variety of foods	My child enjoys a wide variety of foods Never	My child enjoys a wide variety of foods Rarely	My child enjoys a wide variety of foods Sometimes	My child enjoys a wide variety of foods Often	My child enjoys a wide variety of foods Always
My child is difficult to please with meals	My child is difficult to please with meals Never	My child is difficult to please with meals Rarely	My child is difficult to please with meals Sometimes	My child is difficult to please with meals Often	My child is difficult to please with meals Always
My child is interested in tasting food s/he hasn’t tasted before	My child is interested in tasting food s/he hasn’t tasted before Never	My child is interested in tasting food s/he hasn’t tasted before Rarely	My child is interested in tasting food s/he hasn’t tasted before Sometimes	My child is interested in tasting food s/he hasn’t tasted before Often	My child is interested in tasting food s/he hasn’t tasted before Always
My child decides that s/he doesn’t like a food, even without tasting it	My child decides that s/he doesn’t like a food, even without tasting it Never	My child decides that s/he doesn’t like a food, even without tasting it Rarely	My child decides that s/he doesn’t like a food, even without tasting it Sometimes	My child decides that s/he doesn’t like a food, even without tasting it Often	My child decides that s/he doesn’t like a food, even without tasting it Always

8. Families for Life Child Eating Behaviour Questionnaire:
Please tick the boxes most appropriate for your 2nd Child’s eating behaviour.

	Never	Rarely	Sometimes	Often	Always
My child refuses new foods at first	My child refuses new foods at first Never	My child refuses new foods at first Rarely	My child refuses new foods at first Sometimes	My child refuses new foods at first Often	My child refuses new foods at first Always
My child enjoys tasting new foods	My child enjoys tasting new foods Never	My child enjoys tasting new foods Rarely	My child enjoys tasting new foods Sometimes	My child enjoys tasting new foods Often	My child enjoys tasting new foods Always
My child enjoys a wide variety of foods	My child enjoys a wide variety of foods Never	My child enjoys a wide variety of foods Rarely	My child enjoys a wide variety of foods Sometimes	My child enjoys a wide variety of foods Often	My child enjoys a wide variety of foods Always
My child is difficult to please with meals	My child is difficult to please with meals Never	My child is difficult to please with meals Rarely	My child is difficult to please with meals Sometimes	My child is difficult to please with meals Often	My child is difficult to please with meals Always
My child is interested in tasting food s/he hasn’t tasted before	My child is interested in tasting food s/he hasn’t tasted before Never	My child is interested in tasting food s/he hasn’t tasted before Rarely	My child is interested in tasting food s/he hasn’t tasted before Sometimes	My child is interested in tasting food s/he hasn’t tasted before Often	My child is interested in tasting food s/he hasn’t tasted before Always
My child decides that s/he doesn’t like a food, even without tasting it	My child decides that s/he doesn’t like a food, even without tasting it Never	My child decides that s/he doesn’t like a food, even without tasting it Rarely	My child decides that s/he doesn’t like a food, even without tasting it Sometimes	My child decides that s/he doesn’t like a food, even without tasting it Often	My child decides that s/he doesn’t like a food, even without tasting it Always

9. Families for Life Child Eating Behaviour Questionnaire:
Please tick the boxes most appropriate for your 3rd Child’s eating behaviour.

	Never	Rarely	Sometimes	Often	Always
My child refuses new foods at first	My child refuses new foods at first Never	My child refuses new foods at first Rarely	My child refuses new foods at first Sometimes	My child refuses new foods at first Often	My child refuses new foods at first Always
My child enjoys tasting new foods	My child enjoys tasting new foods Never	My child enjoys tasting new foods Rarely	My child enjoys tasting new foods Sometimes	My child enjoys tasting new foods Often	My child enjoys tasting new foods Always
My child enjoys a wide variety of foods	My child enjoys a wide variety of foods Never	My child enjoys a wide variety of foods Rarely	My child enjoys a wide variety of foods Sometimes	My child enjoys a wide variety of foods Often	My child enjoys a wide variety of foods Always
My child is difficult to please with meals	My child is difficult to please with meals Never	My child is difficult to please with meals Rarely	My child is difficult to please with meals Sometimes	My child is difficult to please with meals Often	My child is difficult to please with meals Always
My child is interested in tasting food s/he hasn’t tasted before	My child is interested in tasting food s/he hasn’t tasted before Never	My child is interested in tasting food s/he hasn’t tasted before Rarely	My child is interested in tasting food s/he hasn’t tasted before Sometimes	My child is interested in tasting food s/he hasn’t tasted before Often	My child is interested in tasting food s/he hasn’t tasted before Always
My child decides that s/he doesn’t like a food, even without tasting it	My child decides that s/he doesn’t like a food, even without tasting it Never	My child decides that s/he doesn’t like a food, even without tasting it Rarely	My child decides that s/he doesn’t like a food, even without tasting it Sometimes	My child decides that s/he doesn’t like a food, even without tasting it Often	My child decides that s/he doesn’t like a food, even without tasting it Always

10. Which statement best describes your ethnicity? *

11. Additionally, we have Educational Webinars and Cookalong videos (5–11 years) - These are Quick & easy videos to follow in your own family time. We'll send you food e-vouchers towards the ingredients of each recipe. Would you like to receive these?

Yes please
No thank you

I've already done these, thanks

12. Where did you hear about us? *

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