Application Form - Kids Give Back

School*

School Address*

Street Address City State ZIP Code

School Phone*

School Website

Teacher Name*

First Last

Teacher Email*

Teacher Classroom Phone*

Teacher Cell Phone*

The Grade(s) You Teach*

4th Grade
5th Grade
4th and 5th Grade

How many classrooms will participate in the Kids Give Back program?*

How many students (total) will participate in the Kids Give Back program?*

School Principal Name*

First Last

School Principal Email*

School Principal Office Phone*

School Principal Cell Phone

Preferred Local Food Bank*

Food Bank Address*

Street Address City State ZIP Code

Food Bank Phone*

Please indicate when you would prefer to schedule your Kids Give Back online presentation. (Check all that apply.)*

September 2015
October 2015
November 2015
December 2015

Please indicate which of the following technology you have at your classroom's disposal.

Laptop - REQUIRED
Projector setup (to show presentation) - REQUIRED
Screen (to show presentation) - REQUIRED
Broadband wireless (reliable) - SUGGESTED

Please confirm that your class would be willing and able to bring students to the local food bank of your choice to participate in delivery of the donated grocery items. We strongly encourage this as part of the program, and will use this criterion to help select this year's program participants.*

Yes
No
Uncertain

Please tell us briefly why you would like to participate in Kids Give Back.*

Application Form – Kids Give Back