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2022 Back-To-School Supplies Application

Name ___________________________________________________________ # in Family______
Address __________________________________________________________________________
Telephone ________________________________ Email ___________________________________


       Child’s Full Name                        Gender     Age    School                                Grade
1.    _______________________________________________________________________________

2.    _______________________________________________________________________________

3.    _______________________________________________________________________________

4.    _______________________________________________________________________________

5.    _______________________________________________________________________________


Pre-Tax Monthly Household Income: $______________________


Please initial the following:
I understand this assistance is only for children that live with me full time: ________


Please answer: Yes or No:
Have you received a holiday basket from us in the past? _________
Do you receive food stamps? _________
Do you use our food shelf? _________

I agree by signing this application, I affirm that all of the above information is true and complete to the best of my knowledge. I also give permission for BRGNS to consult with other agencies as an advocate on my behalf.



Date: ________________        _________________________________________




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