Backpack Drive Registration Form

Backpack Drive Registration Form

Please complete this form to register your children for the backpack drive and provide household details.
Parent Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
County
Household Size
Are you the head of household?
Race/Ethnicity
Gender (Parent/Guardian)
Marital Status
Household Monthly Gross Income (USD)
Please provide details for each child aged 5-11
Attestation

By submitting this form, I attest that the information provided is true and accurate to the best of my knowledge. I understand that submitting a registration form does not guarantee that my child/children will receive a backpack or school supplies. Backpacks and supplies are limited and will be distributed based on availability.
I have read and agree to the attestation above.
Should be Empty: