Backpack Request
Please fill in all of your contact information. 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.

*** We are currently distributing in Bradford, Cameron, Lycoming, McKean, Potter and Tioga counties ***

Contact information:

First Name *

Last Name *

Address *

City, State & Zip * (Please include all information)

Phone Number *

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Email address

How did you hear about the Backpack program?

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Please tell us about the children that you are requesting backpacks for. When you are finished entering your information please click "Send Email" at the bottom of this page and then be sure to click "Send Request" on the next page to complete your backpack request. If you have more than 5 children please submit two forms and make a note in the comment field of your second request that this is page 2 of your backpack request.

Child #1 - Boy or Girl

Grade

Child #2 - Boy or Girl

Grade

Child #3 - Boy or Girl

Grade

Child #4 - Boy or Girl

Grade

Child #5 - Boy or Girl

Grade

Please enter any questions,

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