Registered:______

Date:______

2015Back To School BonanzaRegistration

Parent’s Name:______

Address:______

Street City State Zip Code

Phone number: ______Driver’s License or ID #:______

# of Family members in Household: ______# of Children in Household:______

Please check the following services needed:

Back Pack / School SuppliesShoesHaircut

School UniformsDental Screening

Please note: You are strongly encouraged to arrive early to ensure that you receive requested services.

How did you hear about the 2015 Back To School Bonanza Event?

 Friend Flyer Digital Billboard

 Newspaper Radio Other ______

I would like more information on: (A representative would like to provide you the information.)

 Buckner Family Place Foster Care/Foster to Adopt  Maternity/Adoption

OPTIONAL INFORMATION TO AID JR. LEAGUE OF LUFKIN GRANT APPLICATIONS

Family’s monthly income: $______

Did your children receive either reduced or free lunches the previous school year? ___Yes ___ No

Please check the following benefits you are currently receiving:

 Medicaid TANF Disability Food Stamps Unemployment SSI

Please check one or more racial identities:

 White  Black/African American  American Indian/  Hawaiian/

 Hispanic  Asian Alaskan Native Pacific Islander

Please list all Pre-K – 12th grade children living in your home who need supplies.

Name / D.O.B. / Grade
(Fall 2015) / Name of School / For office use only: proof of enrollment

INDEMNITY AND MEDIA RELEASE

I, being 18 years of age or older, do hereby release, forever discharge and agree to hold harmless, Buckner International, Buckner Children & Family Services, Inc., (“Buckner”), Junior League of Lufkin (“JLL”), First United Methodist Church of Lufkin (“FUMC”), and all other volunteers, collectively known as the Back to School Bonanza staff (“B2SB”) and their respective directors, offices, employees and agents thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damages and expenses , of and nature whatsoever which may be incurred by the undersigned that occur while participating in any B2SB related activity or which occur on any B2SB facility or property.

Further, I hereby agree that all photos, audio and video recordings made by B2SB of my likeness, name and voice produced by B2SB, its contractors, agents, or employees, may be published, reproduced, exhibited and/or broadcast, through any media and used by B2SB without further consent or payment. I hereby forever release B2SB, its employees, agents, successors and assigns from any claims, actions, damages, demands whatsoever by reason of such use.

In addition, I authorize that this information may be released to other non-profit agencies.

I certify that the information contained in this application is correct, complete and the children listed are living in my home.

______

SIGNATURE OF PARENT OR GUARDIANPRINT NAMEDATE

______

SIGNATURE OF BUCKNER EMPLOYEEPRINT NAMEDATE