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blue banner with hendricks co fop lodge 132 wording

School Supplies and Clothing Assistance Application

 

Application should be completed and returned to the above address.  Do not leave any spaces blank.  A telephone number must accompany this form.  Your child must attend a school in Hendricks County and be in Grade K – 8 to participate.  On the shopping day, your child will need to bring a copy of the school supply list with them.  (Use back of Form for Additional Children)

 

Child’s Name: _________________________________________  Age:  ___________ Grade:  ________

 

Child’s Name: _________________________________________  Age:  ___________ Grade:  ________

 

Child’s Name: _________________________________________  Age:  ___________ Grade:  ________

 

Name of Responsible Party: _______________________________________________________________

 

Relationship to Child: (Circle One)    Guardian      Parent

 

Address:  _____________________________________________ 

 

City:____________________________

 

Telephone Number:____________________  Best time to call: __________________

 

Total Annual Household Income: (Check One)

______  $0 to $10,000.00

______  $10,000.00 to $15,000.00

______  $15,000.00 to $20,000.00

______  $20,000.00 to $25,000.00

______  $25,000.00 to $30,000.00

______  Over $30,000.00

 

Number of persons in household:  ____________

 

Have you recently been laid off?  (Circle One)  Yes    No

 

Name of School: ______________________________________  First Day of School:  _______________

 

Form should be completed and mailed to:                     Megen Morgan – Secretary

                                                                                                FOP Lodge 132

                                                                                                P.O. Box 132

                                                                                                Plainfield, IN  46168


 

 

Click here for printable Application
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