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2020 Back-To-School 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: $______________________
                                                
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Please initial the following:
I understand this assistance is only for children that live with me full time: ________

Please answer: Yes or No:
Do your children receive free or reduced school lunch? _________
Have you received a holiday basket from us in the past? _________
Are you able to provide your child/children with snacks at school? __________
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 

 

 

 

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    Thrift Store 

37B Main Street

Ludlow, VT 05149

Food Shelf

37B Main Street

Ludlow, VT 05149

 Furniture Store

105 Main Street

Ludlow, VT 05149

Hours:

   Hours:

Monday-Friday

10AM - 3PM

Tuesday-Saturday

10AM - 4PM

Phone: 802-228-3663

Phone: 802-228-3663

Hours:

Friday & Saturday

10AM - 4PM

Phone: 802-228-7055