SUMMER BREAK BAGS- PRE-REGISTRATION

1
Parent/Guardian Name* This field is required.Only list one main name for the account. You can list additional pick-up person(s) later in this form.
First Name
Last Name
2
Parent/Guardian Email* This field is required.
example@example.com
3
Does/Do your child(ren) attend a Hillsborough County Public School in one of the following zip codes? Brandon: 33510, 33511 Dover: 33527 Dover/Sydney: 33587 Lithia: 33547 Plant City: 33563, 33564, 33565, 33566, 33567 Riverview: 33569, 33578, 33579 Seffner: 33584 Thonotosassa: 33592 Valrico 33594, 33596 Wimauma: 33598* This field is required.This program is funded to serve only the above zip codes.
YESNO
4
How many children in your household are K-12th grade in a Hillsborough County Public School in our approved zip codes?* This field is required.
5
What schools K-12th grade does your child(ren) attend?* This field is required.
6
Please provide the names and ages, aged K-12th that live with you in your household.* This field is required.
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7
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
8
I authorize the following individuals to pick up my child(ren)’s Summer Break Food Bag(s). Authorized individuals must present a valid photo ID at pickup.* This field is required.Please list first and last name!
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9
Please answer the below questions:* This field is required.If the answer is 0, put 0.
Annual Household Income (Example: 25,000)
Adults ages 18-64 living in your household
Adults ages 65+ living in your household
Infants ages 0-2 living in your household
Preschoolers ages 3-4 living in your household
School- Age Children ages 5-17 living in your household
10
Thank you for your interest in our Summer Break Food Bag program. At this time, your child’s school zip code falls outside of the current service area approved for this specific program.

We encourage you to visit UFBPC.org to learn more about additional programs, services, and community resources that may be available to your family. 💙
11
I certify that the information provided in this form is accurate to the best of my knowledge. I understand that food items may vary from week to week based on availability, and food bags per family may have quantity limits to help ensure all families are served fairly.* This field is required.
Should be Empty: