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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.
1.
Please choose a time slot for pick-up on January 18th, 2021.
12pm-1pm
4pm-5pm
2.
Parent Name
3.
Child (1)
Name
Gender
Date Of Birth (DOB)
4.
Child (2)
Name
Gender
Date of Birth (DOB)
5.
Child (3)
Name
Gender
Date of Birth
6.
Child (4)
Name
Gender
Date of Birth (DOB)
*
7.
Zipcode and Family size (How many people live in your home?)
(Required.)
Zipcode
Family Size
*
8.
Ethinicity
(Required.)
Hispanic or Latino
Non-Hispanic/Latino
*
9.
Race
(Required.)
White/Caucasion
Hispanic/Latino
Black/African-American
Asian
American Indian/Alaskan Native
Native Hawaiian or Other Pacific Islander
Other/Multi-racial
*
10.
Income Level
(Required.)
$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
11.
Please leave your email if you would like to receive information about upcoming Backpack Buddies programs!