Asbury Backpack Program Application

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Welcome to the Asbury Backpack/Community Assistance Program Application. If needed, your child(ren) will receive a backpack/box full of nutritious food every Friday. As a community we are here to help. No one will be denied.

Please apply below by filling out the following form. This information helps us track who we are serving. Please fill out as much as possible so we can get funding to help more families. We DO NOT every give out names to funders or anyone outside of our program.

Name *

Email *

Phone Number *

Address *

What is your preferred method of communication?

Phone Call

Text Message

What is your preferred language?

Child's Name (#1) *

Child's (#1) Homeroom Teacher *

Child's Name (#2)

Child's (#2) Homeroom Teacher

How many people live in your household?

Are there any allergies or food concerns in your household?

Yes

Clear selection

If you answered yes to the above question, please let us know about any allergies you may have.

How would you like to receive your food? *

Pick Up - I am able to pick up Fridays @ Asbury from 9:30am-10am

Pick Up- I am able to pick up Fridays @ Asbury from 10-10:30am

Delivery - I am unable to pick up in person due to Job, childcare, or other external factors

Comments - Please add anything you would like us to know. (For example, are you in need of household items? Does your family not eat bread?

Submit

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