2016 CANTON BACK TO SCHOOL PROGRAM APPLICATION

Please complete this form and return to Senior & Social Services
by August 12th indicating your interest in this years program
All non-returned forms will be assumed that assistance is not needed this year.
Parent/Guardian Name: ____________________________
Phone#:____________________________
Address: ________________________________________________________________, Canton , CT 06019
EMAIL ADDRESS (please write legibly):______________________________________________________________
Childs Name: _______________________________

Grade: _________

Gender Identity: _________

Childs Name: _______________________________

Grade: _________

Gender Identity: _________

Childs Name: _______________________________

Grade: _________

Gender Identity: __________

Childs Name: _______________________________

Grade: _________

Gender Identity: __________

Childs Name: ______________________________

Grade: _________

Gender Identity: __________

Backpack Needed?

Yes or No Name(s): ____________________________________________________

If yes, color preference (not guaranteed):________________________________________________________

Notes: ____________________________________________________________________________________
Payless Gift Card Requested? Yes or No (circle)
_________________________________________________________________________________________
*We are requesting parental/guardian consent to allow the Canton Public Schools permission to provide the Town of
Canton Senior/Social Services Director information regarding your childs eligibility status for the Reduced/Free Lunch
Program through the schools.
*We are requesting parental/guardian consent to allow the Gifts of Love permission to provide the Town of Canton
Senior/Social Services Director information regarding your childs eligibility status for services through Gifts of Love,
including (but not limited to) the Weekend Food Backpack Program and Back to School Assistance Program through Gifts
of Love.
Signature: ________________________________________ Date: _______________________________
By signing this form I am authorizing the Canton Public Schools and Gifts of Love the right to share information pertaining to my child
with the Town of Canton Senior and Social Services Department.

Return completed form to: CANTON SENIOR & SOCIAL SERVICES, PO BOX 168, COLLINSVILLE CT 06022
or drop-off at: 40 DYER AVENUE, CANTON CT 06019 (office is in lower level of Canton Community Center)

Senior & Social Services Section:

Date/Time scheduled:______________ ______:________

Received form date:__________________

Family Code:__________________

Back to School supplies pick-ups will be scheduled for

Tuesday August 23rd through Friday, August 26th

FAMILY NAME: __________________________

FAMILY CODE: ___________________________
Your scheduled time for pick-up is on __________, August _____ at ____:______.

Please provide staff, upon pick-up, your FAMILY CODE.

This will assist us in ensuring confidentiality. Thank you.