2024 BACKPACK PROGRAM Application Form

2024 Application
Request #: _______________________________________________
Parent/ Guardian Name:*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number 1:*
This number will be used to contact you regarding your backpack pick-up time. It is essential that you include a valid phone number.
Phone Number 2:
Please enter a valid phone number.
Email:
This email may be used to contact you for a survey, related programs, contests, and give aways throughout the year. Please enter a valid email address.
Yearly Household Income:*
This information does not impact your eligibility for this program, and will only be used collectively, as an average for reporting and funding purposes. Entering $0 is not an option.
Have you used the Town House Backpack Program before?*

YesNo
If yes, what was the last year you accessed the Backpack program?
This is for reporting purposes only, and will not reflect eligibility.
Have you applied for assistance from any other backpack program?*

YesNo
If yes, which organization?
Total number of students you're requesting backpacks for:*
If you require more than 5 backpack registrations, please contact Town House once you've completed your form.
Supplies Requested For:

Please include the Name, Date of Birth, Grade, and gender for each student in your household who requires a backpack and supplies.
Please Note:

Although we receive some monatary donations and purchase some supplies ourselves, many of our backpacks and supplies are donated by community members. Therefore some items may have colours or characters that are traditionally viewed as perfered by male or female students.

While we take every effort to distribute gender neutral supplies, we are limited in what we can offer based on donations. Please include your students gender identity if they would prefer, or be comfortable with items displaying colours or characters that are traditionally associated with certian genders.

Answering this question is not required and is simply a means of helping us choose supplies your student will be happy with.
Student 1:*

First NameLast Name
Gender
AGE*
DOB*

MonthDayYear
Grade: Student 1 is ENTERING INTO grade *
Student 2:

First NameLast Name
Gender
AGE
DOB

MonthDayYear
Grade: Student 2 is ENTERING INTO grade
Student 3:

First NameLast Name
Gender
AGE
DOB

MonthDayYear
Grade: Student 3 is ENTERING INTO grade
Student 4:

First NameLast Name
Gender
AGE
DOB

MonthDayYear
Grade: Student 4 is ENTERING INTO grade
Student 5:

First NameLast Name
Gender
AGE
DOB

MonthDayYear
Grade: Student 5 is ENTERING INTO grade
OFFICE USE ONLY
Date called for pick up: _____________________________________

Scheduled pick up date & time: _______________________________

Date of pick up: ___________________________________________

Signature: _______________________________________________
Should be Empty:

2024 Application

Supplies Requested For:

OFFICE USE ONLY