Part I. Garden, Program, and Contact Information
Garden Name
Country Where Garden is Located
Albania Algeria American Samoa Angola Anguilla Antigua Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Bosnia Herzegovina Botswana Brazil British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Chad Chile China Colombia Congo Cook Islands Costa Rica Croatia Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Grenada Guadeloupe Guam Guatemala Guinea Guinea Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Ireland (Republic of) Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kosovo Kosrae Island Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mexico Moldova Mongolia Montserrat Morocco Mozambique Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Ponape Portugal Puerto Rico Qatar Reunion Romania Rota Russia Rwanda Saipan Saudi Arabia Senegal Serbia and Montenegro Seychelles Singapore Slovakia Slovenia Solomon Islands South Africa South Korea Spain Sri Lanka St. Barthelemy St. Croix St. Eustatius St. John St. Kitts and Nevis St. Lucia St. Maarten St. Thomas St. Vincent and the Grenadines Suriname Swaziland Sweden Switzerland Syria Tadjikistan Taiwan Tanzania Thailand Tinian Togo Tonga Tortola Trinidad and Tobago Truk Tunisia Turkey Turkmenistan Turks and Caicos Tuvalu Uganda Ukraine Union Island United Arab Emirates United Kingdom United States Uruguay US Virgin Islands Uzbekistan Vanuatu Venezuela Vietnam Virgin Gorda Wallis and Futuna Western Samoa Yap Yemen Zambia Zimbabwe
Garden Address (include street and number if available, or nearest cross streets if number not known).
Garden Address (additional line, if necessary)
City	State	Zip Code
	Select State ................. Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Name and Address of Action Project Location(s) (if different than above)
Name of Youth Program
Name of Adult Contact
Email Address of Adult Contact
Check here if you do NOT want your email address      posted with your Action Form on our website
Action Project Author(s) (if different than above)
Website Address (Optional)
Name(s) of Gardener(s) Involved in Action Project
Month(s) and Year of Action Project:
From Month .............. January February March April May June July August September October November December	Select a Year ............. 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
To Month .............. Only One Month January February March April May June July August September October November December	Select a Year ............. 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Number of participants involved in Action Project:
Youth
Gardeners
Adult Educators/Volunteers
Part II. Project Report
Write a short description of your Action Project covering the following information. The completed story should be no more than one page single-spaced.
1. Goal (1 paragraph) • What was the goal of the project? • How did you decide on the goal? • What did you learn during the Investigations that helped you plan your project?
2. Steps Taken (1 paragraph) • What steps did you take to reach the goal? • What did you do for the garden or community? • What was the result of the project?
3. Reflections (1 paragraph) • Why was what you did important? • What did you learn from the Action Project? • Based on what you learned, what might you do differently in the future? • Based on what you learned, what new Action Projects might you conduct?
4. Photographs (Optional) Please attach several digital photographs for display on the website. See the guidelines for submitting photographs. Print photographs may be mailed to the address below.
Photo #1 Caption Photo #2 Caption Photo #3 Caption Photo #4 Caption Photo #5 Caption Photo #6 Caption
If you cannot submit the form via the web, you may send it as an attached file to gardenmosaics@cornell.edu. Or you may mail the printer-friendly version of the form to: Garden Mosaics Department of Natural Resources Fernow Hall 16 Cornell University Ithaca, NY 14853

Funding for Garden Mosaics is provided by the National Science Foundation Informal Science Education Program and the College of Agriculture and Life Sciences at Cornell University.