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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: ________________        _________________________________________
                                                                   Parent