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Parent/Caregiver First Name*

Parent/Caregiver Last Name*

Primary Email*

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Primary Phone Number*

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Enter Int'l Number

Number of Legal Guardianship Children in Home

Number of Adoptive Children in Home

Number of Foster Children in Home

FAC Location*

Back to School Children

This section below must be filled out. Please select the number of children needing backpacks using the drop down list. **If your child is in kindergarten select 0 for grade.

Back to School

Child First Name*	Child Last Name*	Child's Date of Birth*	Child's Gender*	Child's Race & Ethnicity*	Child's Grade*	Child's School
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian
				African American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Multiracial Native Hawaiian or Other Pacific Islander Other Unknown White or Caucasian

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