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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: ________________        __________________________________




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