2022 Back-To-School Supplies
Sign-Up Form

New Opportunities collects and distributes school supplies to low-income families in Audubon, Calhoun, Carroll, Dallas, Greene, Guthrie and Sac counties. By completing this application, you give permission to share your information with staff, volunteers and partner organizations in an attempt to provide your household with school supplies. Supplies are limited to pre-school through 8th grade, and we will provide according to income-level. Sign up through July 29, 2022.

We rely on generous community donations to provide the supplies. Please consider writing a thank you that we can pass on to show our gratitude!

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* 1. What county do you live in?

Audubon

Calhoun

Carroll

Dallas

Greene

Guthrie

Sac

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* 2. Are you at or below 200% of the Federal Poverty Level according to the FY2022 Federal Poverty Guidelines? (200% POV household size 2 Annual Gross Income: $34,840, add $9,080 per additional member in your family)

Yes

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* 3. What New Opportunities programs are you currently utilizing? Select all that apply:

Low Income Home Energy Assistance Program (LIHEAP)

Low Income Household Water Assistance Program (LIHWAP)

Weatherization

Head Start/Early Head Start

Women, Infants, and Children (WIC)

Family Development and Self Sufficiency (FaDSS)

Other (please specify)

None of the above

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* 4. Parents/guardians may apply for school supplies for children in their legal custody. Documentation may be required. Supplies are limited and will be distributed according to income level. Do you have legal custody of the child you are registering for school supplies?

Yes

No - please contact your local Family Development Center for more details.

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* 5. Parent/Guardian contact Information

First name

Last name

Address

City/Town

State

ZIP/Postal Code

Email Address

Phone Number

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* 6. Child #1 information

First name *

Last name *

School district *

Building *

Grade entering for 2022-2023 school year *

Child's date of birth *

Child's Gender *

Backpack needed?

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* 7. Child #2 information

First name

Last name

School district

Building

Grade entering for 2022-2023 school year

Child's date of birth

Child's gender

Backpack needed?

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* 8. Child # 3 information

First name

Last name

School district

Building

Grade entering for 2022-2023 school year

Child's date of birth

Child's gender

Backpack needed?

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* 9. Child # 4 information

First name

Last name

School district

Building

Grade entering for 2022-2023 school year

Child's date of birth

Child's gender

Backpack needed?

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* 10. Child # 5 information

First name

Last name

School district

Building

Grade entering for 2022-2023 school year

Child's date of birth

Child's gender

Backpack needed?

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* 11. Child # 6 information

First name

Last name

School district

Building

Grade entering for 2022-2023 school year

Child's date of birth

Child's gender

Backpack needed?

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* 12. Child # 7 information

First name

Last name

School district

Building

Grade entering for 2022-2023 school year

Child's date of birth

Child's gender

Backpack needed?

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* 13. Child # 8 information

First name

Last name

School district

Building

Grade entering for 2022-2023 school year

Child's date of birth

Child's gender

Backpack needed?

2022 Back-To-School Supplies Sign-Up Form

Question Title

* 1. What county do you live in?

Question Title

* 2. Are you at or below 200% of the Federal Poverty Level according to the FY2022 Federal Poverty Guidelines? (200% POV household size 2 Annual Gross Income: $34,840, add $9,080 per additional member in your family)

Question Title

* 3. What New Opportunities programs are you currently utilizing? Select all that apply:

Question Title

* 4. Parents/guardians may apply for school supplies for children in their legal custody. Documentation may be required. Supplies are limited and will be distributed according to income level. Do you have legal custody of the child you are registering for school supplies?

Question Title

* 5. Parent/Guardian contact Information

Question Title

* 6. Child #1 information

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* 7. Child #2 information

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* 8. Child # 3 information

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* 9. Child # 4 information

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* 10. Child # 5 information

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* 11. Child # 6 information

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* 12. Child # 7 information

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* 13. Child # 8 information

2022 Back-To-School Supplies
Sign-Up Form