informational flyer and application form

'Stuff the Bus – Stuff the Desk' Registration Form. Community School Supplies Drive and Distribution. Student Name(s): ... Non Custodial Parent Name(s): ...
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MAIL TO UNITED WAY, 351 OAK STREET, WISCONSIN RAPIDS, 54494 BETWEEN MAY 1ST AND JULY 22ND (In August a postcard will be mailed to you with your school supply pick up time)

‘Stuff the Bus – Stuff the Desk’ Registration Form Community School Supplies Drive and Distribution

Student Name(s): _______________________________

School Attending: _______________________ Grade: ________

Student Name(s): _______________________________

School Attending: _______________________ Grade: ________

Student Name(s): __________________________

School Attending: _______________________ Grade: ________

Student Name(s): __________________________

School Attending: _______________________ Grade: ________

Student Name(s): __________________________

School Attending: _______________________ Grade: ________

Custodial Parent Name(s): ______________________

Address: _______________________ City: ____________________

Non Custodial Parent Name(s): ____________________________ Presently, where is the student(s) living? with parent(s)/guardian in own home or apt in a shelter or temporary foster care in a motel, car, or campsite in transitional housing with another family due to loss of housing or as a result of economic hardship with friends or family members other than a parent/guardian student living in own apt. or home other – please explain: (Optional) Does your family qualify for the free or reduced school lunch program? Yes _____

No _____

The school supplies that you are receiving are a result of community donations that have been collected. If there are items on the school supply list that have not been provided and you are concerned, please contact your child’s school. The information that you have provided on this form will be shared with your child’s school district. I have read and understand the above statement.

_________________________________________ Parent Signature (Required to receive supplies)

___________ Date