Backpack Requests for Students

Childs Last Name

Childs First Name

Phone Number

Grade for 2026-2027 Year

Child's age

This request is for my child and they will be in attendance at the event.

Yes

Are you receiving assistance from any other back-to-school programs?

Yes

School District child will be attending?

School Name

Parent's First and Last Name?

How did you hear about us?

I'm requesting help with...

I understand this form is for ONE child. If I have multiple children, additional forms needs to be filled out.

Yes

Any additional comments, concerns or special circumstances?

Privacy Notice: All information provided will be kept confidential and used only for the purpose of this program. We are committed to protecting your privacy and will not share your information.

I understand and agree to the privacy policy and consent to the use of this information for the Backpack Squad Program.

Photographers may be present at events and I understand my photo may be taken and shared to social media. If you are part of the Safe at Home Program, please indicate in the comments section.

Yes

Coon Rapids - 2026

Aug 18, 2026, 6:00 PM – 8:00 PMThe Healthy Boulevard