UPLIFT 2021-22 Pine River Kids Backpack Program
USDA Proxy Form to enroll students in the UPLIFT PINE RIVER KIDS BACKPACK PROGRAM: 2021-22 School Year
YOU MUST COMPLETE THIS FORM TO ENROLL IN THE UPLIFT FOOD PROGRAM; ALL INFORMATION IS CONFIDENTIAL. Please read the following statement carefully, complete the requested information and sign (type name) below to receive food from this distribution. By typing my name on this form, I declare that I am either: 1. in need of emergency food, OR 2. a participant in an income based program such as WIC, CSFP, cash assistance (FIP) or food stamps (FAP) or qualify for free or reduced lunch. Students listed will have my permission to receive a backpack that may contain USDA food products. You agree to be responsible to check contents of food bags for any food allergies your child(ren) may have. PLEASE TYPE PARENT/GUARDIAN NAME AND DATE *
Head of Household *
Address: Street, City, State, Zip Code *
Contact Phone Number *
Total number in household *
Name of child for this form (you will need to complete a separate form for each child) *
What school does the above named child attend *
What grade is the above named child currently in? *
GRADES 8-12 ONLY: High school students have the option to receive an after school bag (grab and go snacks). Please indicate your options for HS student only.
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