January Backpack Buddies Registration

Please use this form to register your child(ren) to receive a Backpack Buddy.

All information is kept confidential and only used for funding purposes to provide our free programs.

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* 1. Please choose a time slot for pick-up on January 18th, 2021.

12pm-1pm

4pm-5pm

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* 2. Parent Name

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* 3. Child (1)

Name

Gender

Date Of Birth (DOB)

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* 4. Child (2)

Name

Gender

Date of Birth (DOB)

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* 5. Child (3)

Name

Gender

Date of Birth

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* 6. Child (4)

Name

Gender

Date of Birth (DOB)

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* 7. Zipcode and Family size (How many people live in your home?)

Zipcode

Family Size

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* 8. Ethinicity

Hispanic or Latino

Non-Hispanic/Latino

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* 9. Race

White/Caucasion

Hispanic/Latino

Black/African-American

Asian

American Indian/Alaskan Native

Native Hawaiian or Other Pacific Islander

Other/Multi-racial

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* 10. Income Level

$12,000-$20,000

$21,000-$25,000

$26,000-$30,000

$31,000-$35,000

$36,000-$40,000

$41,000-$45,000

$46,000-$50,000

$51,000-$55,000

$56,000-$60,000

$61,000-$65,000

$66,000 or greater

January Backpack Buddies Registration

Please use this form to register your child(ren) to receive a Backpack Buddy.

Question Title

* 1. Please choose a time slot for pick-up on January 18th, 2021.

Question Title

* 2. Parent Name

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* 3. Child (1)

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* 4. Child (2)

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* 5. Child (3)

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* 6. Child (4)

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* 7. Zipcode and Family size (How many people live in your home?)

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* 8. Ethinicity

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* 9. Race

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* 10. Income Level

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* 11. Please leave your email if you would like to receive information about upcoming Backpack Buddies programs!