"Back to School Bash" - Gervonni Cares, Inc.

BACK TO SCHOOL BASH REGISTRATION FORM
BEFORE YOU SIGN UP-PLEASE NOTE

Date of Event: Saturday, July 26, 2025

Time: 10 AM - 12 PM

Location: Chicken N' Pickle (Glendale)

*Parent or Guardian & child(ren) must be present to receive backpack filled with school supplies.
Parent completing form Full Name ONLY*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*

Please provide information below pertaining to school-aged child(ren) in your household ONLY:*

	Full Name (must provide for our records) ...........................................................................................	Grade	Gender (if you prefer)
1
2
3
4

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