FY21 Backpack Application BACKPACK APPLICATION SECTION I: SITE INFORMATIONORGANIZATION NAME:* PROGRAM CONTACT NAME:* First Last Email* Phone*NAME OF SITE CONTACT* EMAIL FOR SITE CONTACT* PHONE NUMBER FOR SITE CONTACT*ACTUAL ADDRESS WHERE BACKPACKS WILL BE DELIVERED* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code COUNTY* ASHLAND ASHTABULA CUYAHOGA GEUAGA LAKE RICHLAND SECTION II: PROGRAM INFORMATIONNUMBER OF VOLUNTEERS/STAFF INVOLVED IN PROGRAM?*Please enter a number greater than or equal to 0.Hiddenhidden: AGE RANGE OF CHILDREN IN PROGRAM AGE RANGE OF CHILDREN IN PROGRAM*Select all that apply. 0-5 YEARS OLD 6-10 YEARS OLD 11-18 YEARS OLD NUMBER OF CHILDREN IN PROGRAM*START DATE* MM slash DD slash YYYY HiddenHIDDEN: END DATE*2020-2021 BACKPACK PROGRAM ENDS AT THE END OF YOUR SCHOOL YEAR MM slash DD slash YYYY How frequently would you like your delivery?* Weekly Bi-weekly PLEASE SPECIFY YOUR PREFERRED DELIVERY DAY-1ST CHOICE*PLEASE SELECT YOUR FIRST CHOICE OF DELIVERY DAY. MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY PLEASE SPECIFY YOUR PREFERRED DELIVERY DAY-2ND CHOICE*PLEASE SELECT YOUR SECOND CHOICE OF DELIVERY DAY. MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY PLEASE SPECIFY THE BEST TIME OF DAY TO RECEIVE YOUR DELIVERY* : Hours Minutes AM PM AM/PM Please upload a file containing your School Year Calendar to include all days open/closed*Please indicate your days open/closed for service.Max. file size: 49 MB.PLEASE DESCRIBE THE BACKPACK STORAGE AREA:*IS THE BACKPACK STORAGE AREA SECURE AND LOCKED?* YES NO SECTION III: DISTRIBUTION INFORMATIONTHE BACKPACK WAS INTENDED TO ENSURE THAT CHILDREN HAVE ACCESS TO WEEKEND MEALS. THEREFORE, BACKPACKS SHOULD BE DISTRIBUTED ON FRIDAY.PLEASE ADVISE WHAT TIME YOU WILL DISTRIBUTE YOUR BACKPACKS.* : Hours Minutes AM PM AM/PM PLEASE DESCRIBE HOW YOU WILL DISTRIBUTE THE BACKPACKS EACH WEEK.*PLEASE DESCRIBE HOW YOU WILL COMMUNICATE WITH THE PARENTS/GUARDIANS OF CHILDREN ENROLLED IN THE BACKPACK PROGRAM.*SIGNATURE*Please type your name to sign the application. NameThis field is for validation purposes and should be left unchanged.
