Wheels of Learning Back-to-School EventBack-to-School Supply Initiative: Students Grades K-12 Survey

1.Personal Information(Required.)

Date:

Name:

Phone:

Address:

Zip Code:

Email:

2.Full name of students(Required.)

Student 1

Student 2

Student 3

Student 4

Student 5

Student 6

Student 7

3.Student Information(Required.)

Age

Grade

School Name

School Districts

Student 1

Student 2

Student 3

Student 4

Student 5

Student 6

Student 7

4.Total Number of Household Members(Required.)

6.Eligibility Criteria/Proof of Income - Paycheck Stubs are not accepted(Required.)

2024 Tax Return

Federal Pell Grant

Medicaid or Medical Assistance (Bring a Document that says "MA or "Medical Assistance" on it )

Section 8 or other Federal Public Housing Assistance ( A copy of lease in required)

SNAP (Food Stamps) (Benefit Letter)

Supplemental Security Income (SSI) (Benefit Letter)

Temporary Assistance for Needy Families (TANF) (A 2025 dated letter showing current eligibility is required)

WIC - Women infants and Children (Benefit Letter)

Please submit the proof of income documents to OIC@topeka.org or bring them in person to the Cyrus K. Holliday Building located at 620 SE Madison Avenue.