Section 1 of 1 in this document

BACK TO SCHOOL PROGRAM 2024

Bristol Parks, Recreation, Youth and Community Services (BPRYCS) is coordinating the Back-to-school Backpack Program to assist families in need of backpacks and/or school supplies to assist with a smooth transition back to school.

*Forms need to be returned by Friday, August 9, 2024

Attach 1 month’s income verification and number of children in the household. Income verification includes pay stubs from wages, and/or statement of benefits received from unemployment, social security, child support, and DSS benefits including SNAP.

If you have any questions, please contact Raven Cody at BPRYCS (860) 314-4690.

We will contact you to schedule pick-up for your items at: 51 High Street, Bristol, CT 06010

Child Name (First & Last)

Parent/Guardian Name (First & Last)

Date Referred

Phone Number (home/work/cell)

Referring Agency/School

Agency Phone Number

Referring Agency Contact Person

Backpack & Supplies

Gender - Please select one

Male

Female

Transgender

Nonbinary

Other

Child Age

Grade in September

School

Backpack & Supplies Color/Style Preferred

Do you have another child to add?

Yes

Child Name #2 (First & Last)

Gender Child #2 - Please select one

Male

Female

Transgender

Nonbinary

Other

Child #2 Age

Grade in September - Child #2

School - Child #2

Backpack & Supplies Color/Style Preferred - Child #2

Do you have a third child to add?

Yes

Child Name #3 (First & Last)

Gender Child #3 - Please select one

Male

Female

Transgender

Nonbinary

Other

Age - Child #3

Grade in September - Child #3

School - Child #3

Backpack & Supplies Color/Style Preferred - Child #3

Do you have a fourth child to add?

Yes

Child Name #4 (First & Last)

Gender Child #4 - Please select one

Male

Female

Transgender

Nonbinary

Other

Age - Child #4

Grade in September - Child #4

School - Child #4

Backpack & Supplies Color/Style Preferred - Child #4

Do you have a fifth child to add?

Yes

Child Name #5 (First & Last)

Gender Child #5 - Please select one

Male

Female

Transgender

Nonbinary

Other

Age - Child #5

Grade in September - Child #5

School - Child #5

Backpack & Supplies Color/Style Preferred - Child #5

UPLOAD FILE(S) - Attach 1 month’s income verification and number of children in the household. Income verification includes pay stubs from wages, and/or statement of benefits received from unemployment, social security, child support, and DSS benefits including SNAP.

UPLOAD FILE(S) - Please attach proof of Bristol address.

Parent/Guardian Signature

First Name

Last Name

Choose how to sign

Draw Type

I authorize Bristol Parks, Recreation, Youth & Community Services to contact other agencies in the community providing backpacks and school supplies to avoid duplication. I understand that my child’s first name, age and preferences might be released to a donor.

BACK TO SCHOOL PROGRAM 2024

Date Referred

Full Address

Backpack & Supplies

Gender - Please select one

Do you have another child to add?

Gender Child #2 - Please select one

Do you have a third child to add?

Gender Child #3 - Please select one

Do you have a fourth child to add?

Gender Child #4 - Please select one

Do you have a fifth child to add?

Gender Child #5 - Please select one

UPLOAD FILE(S) - Attach 1 month’s income verification and number of children in the household. Income verification includes pay stubs from wages, and/or statement of benefits received from unemployment, social security, child support, and DSS benefits including SNAP.

UPLOAD FILE(S) - Please attach proof of Bristol address.

Parent/Guardian Signature