Backpack Request
Please fill in the information shown below. Item's marked with an * are required. Please supply us with as much information as you can. We will only use this information for tracking purposes to verify where the backpacks are being distributed. We must have an email or telephone number so that we can make arrangements to get your backpack(s) to you. Your information will not be used for mailing lists, etc. Please only request a backpack because it is needed, not because it is free. We have many children to supply backpacks and the one's that are taken and not needed are the one's that keep a child from receiving one.

Please note: we do not distribute outside of our current Tri-County area. We are working on expanding our coverage area but at this time we must stay within Potter, McKean and Tioga county.

Name*

First

Last

Address

City, State & Zip

Phone Number

###

####

Email

How did you hear about the Backpack program?

*****************************************************************

Please tell us about the children that you are requesting backpacks for. When you are finished entering your information please click submit at the bottom of the page.

Child #1 - Boy or Girl

Child #1 - Grade

Child #2 - Boy or Girl

Child #2 - Grade

Child #3 - Boy or Girl

Child #3 - Grade

Child #4 - Boy or Girl

Child #4 - Grade

Child #5 - Boy or Girl

Child #5 - Grade

Child #6 - Boy or Girl

Child #6 - Grade

Please enter questions, comments or suggestions
below