Language
English (US)
Spanish (Latin America)
Backpack Drive / Recolección de mochilas
To change between English and Spanish translation, click the button on the top right.
Para cambiar entre la traducción al inglés y al español, haga clic en el botón en la parte superior derecha.
Parent Name
*
First Name (required)
Last Name (required)
Parent Date of Birth (required mm/dd/yyyy)
*
/
Month
/
Day
Year
Date
Parent Race
*
White
Black/African American
Japanese
Korean
American Indian
Guamanian
Chinese
Native Hawaiian
Vietnamese
Filipino
Asian Indian
Samoan
Other
Parent Ethnicity
*
Not Hispanic
Yes, Mexican, Mexican American, Chicano
Yes, Brazilian
Yes, another Hispanic, Latino, or Spanish Origin
Yes, Puerto Rican
Yes, Cuban
Other
Parent Email Address
*
example@example.com
Parent Phone Number
Preferred Contact Method
Text
Email
Phone
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Language
Does your family need support with food and/or clothing?
Yes
No
Back
Next
Child Name (to sign up for a backpack)
*
First Name
Last Name
Child Date of Birth (required mm/dd/yyyy)
*
/
Month
/
Day
Year
Date
Child Race
*
White
Black/African American
Japanese
Korean
American Indian
Guamanian
Chinese
Native Hawaiian
Vietnamese
Filipino
Asian Indian
Samoan
Other
Child Ethnicity
*
Not Hispanic
Yes, Mexican, Mexican American, Chicano
Yes, Brazilian
Yes, another Hispanic, Latino, or Spanish Origin
Yes, Puerto Rican
Yes, Cuban
Other
What Grade will they be entering for the Fall?
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
What School/School Program will they attend for the Fall?
Would you like to Register another child?
*
Yes
No
Back
Next
Child Name (to sign up for a backpack)
*
First Name
Last Name
Child Date of Birth (required mm/dd/yyyy)
*
/
Month
/
Day
Year
Date
Child Race
*
White
Black/African American
Japanese
Korean
American Indian
Guamanian
Chinese
Native Hawaiian
Vietnamese
Filipino
Asian Indian
Samoan
Other
Child Ethnicity
*
Not Hispanic
Yes, Mexican, Mexican American, Chicano
Yes, Brazilian
Yes, another Hispanic, Latino, or Spanish Origin
Yes, Puerto Rican
Yes, Cuban
Other
What Grade will they be entering for the Fall?
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
What School/School Program will they attend for the Fall?
Would you like to Register another child?
*
Yes
No
Back
Next
Child Name (to sign up for a backpack)
*
First Name
Last Name
Child Date of Birth (required mm/dd/yyyy)
*
/
Month
/
Day
Year
Date
Child Race
*
White
Black/African American
Japanese
Korean
American Indian
Guamanian
Chinese
Native Hawaiian
Vietnamese
Filipino
Asian Indian
Samoan
Other
Child Ethnicity
*
Not Hispanic
Yes, Mexican, Mexican American, Chicano
Yes, Brazilian
Yes, another Hispanic, Latino, or Spanish Origin
Yes, Puerto Rican
Yes, Cuban
Other
What Grade will they be entering for the Fall of?
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
What School/School Program will they attend for the Fall of?
Would you like to Register another child?
*
Yes
No
Back
Next
Child Name (to sign up for a backpack)
*
First Name
Last Name
Child Date of Birth (required mm/dd/yyyy)
*
/
Month
/
Day
Year
Date
Child Race
*
White
Black/African American
Japanese
Korean
American Indian
Guamanian
Chinese
Native Hawaiian
Vietnamese
Filipino
Asian Indian
Samoan
Other
Child Ethnicity
*
Not Hispanic
Yes, Mexican, Mexican American, Chicano
Yes, Brazilian
Yes, another Hispanic, Latino, or Spanish Origin
Yes, Puerto Rican
Yes, Cuban
Other
What Grade will they be entering for the Fall?
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
What School/School Program will they attend for the Fall?
Would you like to Register another child?
*
Yes
No
Back
Next
Child Name (to sign up for a backpack)
*
First Name
Last Name
Child Date of Birth (required mm/dd/yyyy)
*
/
Month
/
Day
Year
Date
Child Race
*
White
Black/African American
Japanese
Korean
American Indian
Guamanian
Chinese
Native Hawaiian
Vietnamese
Filipino
Asian Indian
Samoan
Other
Child Ethnicity
*
Not Hispanic
Yes, Mexican, Mexican American, Chicano
Yes, Brazilian
Yes, another Hispanic, Latino, or Spanish Origin
Yes, Puerto Rican
Yes, Cuban
Other
What Grade will they be entering for the Fall?
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
What School/School Program will they attend for the Fall?
Would you like to Register another child?
*
Yes
No
Back
Next
Child Name (to sign up for a backpack)
*
First Name
Last Name
Child Date of Birth (required mm/dd/yyyy)
*
/
Month
/
Day
Year
Date
Child Race
*
White
Black/African American
Japanese
Korean
American Indian
Guamanian
Chinese
Native Hawaiian
Vietnamese
Filipino
Asian Indian
Samoan
Other
Child Ethnicity
*
Not Hispanic
Yes, Mexican, Mexican American, Chicano
Yes, Brazilian
Yes, another Hispanic, Latino, or Spanish Origin
Yes, Puerto Rican
Yes, Cuban
Other
What Grade will they be entering for the Fall?
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
What School/School Program will they attend for the Fall?
Back
Next
Database Consent
This Family Center program is supported by the Children’s Trust and the Department of Early Education and Care (EEC) and evaluation partners at Tufts University. We are asking for you to provide us with information about you and your family. We will keep your data secure and protect your privacy. Data reports will only be presented in aggregate, we will never include your name or individual information in any reports.
I consent to my information being shared with the Family Center / SAFE Child Network as described above. Please Type your name.
First Name
Last Name
Signature
*
Today's Date
*
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Day
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