CRCNCW Backpack Registration 2026

1
Registration is open from May 11th until midnight June 12th.

Please note: This program is open only for families who live within Centre Wellington, Wellington North, Minto and Mapleton townships. Please Note: We are only able to assist families who live within these areas due to funding limitations. Also Note: Registering for the program does not guarantee that we can support your needs/request for a backpack/supplies at the time of registration due to registration numbers.

Our Outreach staff will reach out to you if you are a new registrant to verify that you qualify for the program. If you have any details you wish to talk about or accommodations, we can discuss these with you.

Please note: We will do our best to accept referrals after the deadline but supplies may be limited or run out and we will notify you if we are unable to meet your need. Our program is based on registration levels. You can reach our staff at: 519-843-7000 Press 1 for Outreach ext 1.

Backpacks will be ready for pick up from July 20th to July 24th 2026.
2
Are you a Social Worker/Agency referring this family or entering this form on behalf of a family?Only Answer if you are a service provider/agency
YESNO
3
Referring Social Agency/Worker Contact informationPlease enter your Name/Agency/Email
Name
Agency
Email
4
Name of Parent/Guardian 1* This field is required.
First Name
Last Name
5
Name of Parent/Guardian 2Only if there are 2 parents/guardians in the household
First Name
Last Name
6
Data Collection

Please note the below questions are for funding data collection purposes only and to better understand the demographics of the households we support. Your answers here will not be taken into consideration when confirming your enrollment into the Backpack Program. Information regarding the families and individuals we serve help us in serving our communitites more and in learning the unique needs of each rural area.
7
Language spoken at home
English
French
Low German
Arabic
Mandarin
Punjabi
Hindi
Ukrainian
Other
8
Which of the following best describes your household ethnicity?
Black (African, African-Canadian, Afro-Caribbean descent)
East Asian (Chinese, Korean, Japanese, Taiwanese descent)
South Asian (South Asian descent, eg., East Indian, Pakistani, Sri Lankan, Indo-Caribbean, etc.)
White (European Descent)
Indigenous (First Nations, Metis, Inuit)
Latino (Latin American, Hispanic descent)
Middle Eastern (Arab, Persian, West Asian descent eg: Afghan, Egyptian, Iranian, etc.)
Southeast Asian (Filipino, Vietnamese, Cambodian, Thai, other Southeast Asian descent)
Another race category
9
Phone Number* This field is required.
Area Code
Phone Number
10
Email* This field is required.
example@example.com
11
Which of the following towns do you live in?* This field is required.
Please Select
Please Select
Alma
Arthiur
Belwood
Clifford
Conn
Drayton
Elora
Fergus
Harriston
Kenilworth
Moorefield
Mount Forest
Palmerston
Wallenstein
12
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
13
How many children/youth in your household are in need of a backpack and supplies for the upcoming school year?* This field is required.If your child/youth is only needing a backpack or just supplies please make a note at the end in the comments section!
Please Select
Please Select
1
2
3
4
5
6
7
14
Child number 1, Prounouns* This field is required.
Please Select
Please Select
She/Her
He/Him
They/Them
15
Child 1 date of birth?* This field is required.
Date
Year
Month
Day
16
Grade they will be entering in September 2026?* This field is required.
Please Select
Please Select
JK/SK
1-3
4-6
7-8
9
10-12
17
Child number 2, Pronouns* This field is required.
Please Select
Please Select
She/Her
He/Him
They/Them
18
Child 2 date of birth?* This field is required.
Date
Year
Month
Day
19
Grade they will be entering in September 2026?* This field is required.
Please Select
Please Select
JK/SK
1-3
4-6
7-8
9
10-12
20
Child 3 Pronouns* This field is required.
Please Select
Please Select
She/Her
He/Him
They/Them
21
Child 3 date of birth?* This field is required.
Date
Year
Month
Day
22
Grade they will be entering in September 2026?* This field is required.
Please Select
Please Select
JK/SK
1-3
4-6
7-8
9
10-12
23
Child 4 Pronouns* This field is required.
Please Select
Please Select
She/Her
He/Him
They/Them
24
Child 4 date of birth?* This field is required.
Date
Year
Month
Day
25
Grade they will be entering in September 2026?* This field is required.
Please Select
Please Select
Jk/SK
1-3
4-6
7-8
9
10-12
26
Child 5 Pronouns?* This field is required.
Please Select
Please Select
She/Her
He/Him
They/Them
27
Child 5 date of birth?* This field is required.
Date
Year
Month
Day
28
Grade they will be entering in September 2026?* This field is required.
Please Select
Please Select
JK/SK
1-3
4-6
7-8
9
10-12
29
Child 6 Pronouns?* This field is required.
Please Select
Please Select
She/Her
He/Him
They/Them
30
Child 6 date of birth?* This field is required.
Date
Year
Month
Day
31
Grade they will be entering in September 2026?* This field is required.
Please Select
Please Select
JK/SK
1-3
4-6
7-8
9
10-12
32
Child 7 Pronouns?* This field is required.
Please Select
Please Select
She/Her
He/Him
They/Them
33
Child 7 date of birth?* This field is required.
Date
Year
Month
Day
34
Grade they will be entering in September 2026?* This field is required.
Please Select
Please Select
JK/SK
1-3
4-6
7-8
9
10-12
35
Will you need transportation to pick up your backpack(s)?
YESNO
36
Which town would you like to pick your backpack(s) up?* This field is required.
Please Select
Please Select
Arthur
Fergus
Mount Forest
Palmerston
37
Notes/Comments: If you have over 7 children attending school, please use this box to enter more details regarding their pronouns, date of birth, grade for the fall and need for backpack/supplies. Please also use this area to let us know if you are only needing a backpack or just supplies and any other details you want us to know. Thank you
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