Kickstart2School: Shoes and School Supplies Application Form

Parent/Guardian Name*

First NameLast Name

Parent/Guardian Email

example@example.com

Parent/Guardian Phone Number*

Number of Children Applying For*

If you participate in any of these programs, please check all that apply.*

Low Income Home Energy Assistance Program (LIHEAP)Social Security Disability Income/Social Security Income (SSDI/SSI)Supplemental Nutrition Assistance Program (SNAP) (formerly known as food stamps)Temporary Assistance for Needy Families (TANF)Women, Infant and Children Supplemental Nutrition (WIC)Free or Reduced School Lunch ProgramNo incomeOther

If your child is not school age K-12, we are not able to provide a pair of shoes and other items for you child at this time. Thank you for your understanding.

Complete one row for each student.*

If you have chosen Other or NPFB Client, please enter your students school name. (in the same order as above)

Complete one row for each child (in the same order as above) Sponsored by Soles4Souls *

Complete one row for each child (in the same order as above) Sponsor Pending*

Appointment*

We will have following services for students free of charge:

Vison To Learn: Eye exams for all students & 20 students will receive a new pair of glasses.
Virginia Garcia Memorial Health Center: Dental screenings and vaccinations. Please bring the students vaccination records and insurance card if covered by insurance, but not required.
Back to school haircuts

Parents/Guardians must review the acknowledgment and consent agreement before proceeding with the shoe order.

1. I acknowledge that free shoes, coats & school supplies are not guaranteed. Free shoes, coats & school supplies depend on availability and corporate sponsorship.

2. I acknowledge and consent that my child must be present to receive shoes, coat and school supplies.

3. I understand all children must be accompanied by a parent or guardian.

4. I understand that photographs and videos of my child (named above) may be captured during the event, and their likeness may be utilized by print and broadcast media or by the North Plains Food Bank and its sponsors for promoting Kickstart2School.

I give permission to be photographed/video*

YesNo

Signature*

Date*

Date

Brought to you by: North Plains Food Bank

Kickstart2School: Free Shoes and School Supplies Application Form Location: North Plains Elementary School 32030 NW North Ave., North Plains

Parent/Guardian Information

Child's Information