Back to School Supplies Application

School Supplies Request Form

Pick-up will be in August, date TBD. We have a limited number of supplies, so please only apply if this is truly a need for your family.

Name(Required)

First Last

Partner's Name

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Preferred Method of Communication:(Required)

Phone

Please list the following for each child in the household needing school supplies: Name, Grade (in the Fall), Gender, School (Please use numbered list to identify separate children)(Required)

Please share why this is a need for your family:(Required)

Average MONTHLY Income (includes wages/paychecks, MDHHS benefits, etc.) - please note this will NOT affect your ability to receive assistance, it is just for our records.(Required)

$0-$1,000

$1,001-$1,500

$1,501-$2,000

$2,001-$2,500

$2,501+

Average Monthly Expenses (including mortgage/rent, utilities, other bills, food, etc.)(Required)

Back to School Supplies Application

School Supplies Request Form

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