Backpack Request

 

Please note: Please do not request a backpack if you are outside of our distribution area.  We currently only distribute backpacks in Bradford, Cameron,

Lycoming, McKean, Potter and Tioga counties.  Please check locally for a program that may be able to help you if you are not located in one of these counties.

 

Name*

First

Last
 
Address
 
City, State & Zip
 
Phone Number

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-
###
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####
 
Email
 
How did you hear about the Backpack program?
 

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Please tell us about the children that you are requesting backpacks for. When you are finished entering your information please click submit at the bottom of the page.
Child #1 - Boy or Girl
 
Child #1 - Grade
 
Child #2 - Boy or Girl
 
Child #2 - Grade
 
Child #3 - Boy or Girl
 
Child #3 - Grade
 
Child #4 - Boy or Girl
 
Child #4 - Grade
 
Child #5 - Boy or Girl
 
Child #5 - Grade
 
Child #6 - Boy or Girl
 
Child #6 - Grade
 

Please enter questions, comments or

suggestions below

 

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