Backpacks & Snacks
Note: Backpacks are for students K thru 12 and they must be present to receive backpacks. This registration does not guarantee a backpack. They will be given out on a first come first serve basis.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
City of Residence
*
East Orange
Irvington
Newark
Other
E-mail
*
example@example.com
Phone Number
-
Area Code
Phone Number
Will you be accepting groceries?
*
Please Select
Yes
No
Are you a U.S. Military Veteran
No
Yes, I'm Active Military
Yes, I'm Retired
Other
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Household Information
This Information provided through this form is used to assist UCC in expanding the services we provide by identifying the demographics of the clients we serve.
Household Income
*
Please Select
No Income to $12,000
$26,000 to $40,000
Over $40,000
# of Children (Ages 0 - 18)
*
Please Select
None
1
2
3
4
5
6
7
8
9
10
# of Adults (Ages 18 - 62)
*
Please Select
None
1
2
3
4
5
# of Seniors (Over age 62)
*
Please Select
None
1
2
3
4
Race/Ethnicity
*
African American
Hispanic / Latino
Caucasian
Asian
Prefer Not To Say
Other
Gender
*
Male
Female
Other
Signature
*
Submit Form
Submit Form
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