Back to School Event Registration Form

Parent/Guardian's Name

First NameLast Name

Date: Saturday, July 25th

Time: 11am - 1pm

Location: Henry Brigham Community Center

Rules & Requirements

Children must be present to recieve supplies. No exceptions.
Students must be under grade 12.
To recieve health screenings this form should be filled out by the parent/guardian only. *There may be additional information required.

Email

example@example.com

How many children are attending the event?

Please check the grades of your student(s)

Are you interested in health screenings for your children? Please check all that apply.

Are you a medicaid recipient? Please check all that apply.

What zipcode do you live in?

Did you attend this event last year?

What schools do your children attend?