Back 2 School Application "*" indicates required fields Step 1 of 5 20% Participation in this program is limited and will be filled on a first come, first served basis. At the end of this application, you will be asked to upload the following documents. Please be prepared with pdf, png, gif, or jpg copies of these files. A handwritten letter stating your situation A copy of valid photo ID A copy of each child's birth certificate (legal guardianship paperwork if you are not the biological parent.) (DO NOT SEND SOCIAL SECURITY OR PASSPORT) A copy of the most recent electric or phone bill A copy of the Food Letter, Medicaid letter, or any other form of government assistance Note: Once we receive the COMPLETED application and documentation, you will be eligible for the Back2School program. This program will have a limited number of recipients. Children must be enrolled in school. If your contact information (phone number or address) changes, please call our office to update your information. By submitting this form, you also agree to allow photographs of you and/or your children to be published in any HCC publication. By submitting this form, you agree to HCC's Waiver, Assumption of Risk, and Indemnification Agreement found at houstonchildrenscharity.org/waiver/ Contact InformationName* First Last Spouse Name First Last Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email* Enter Email Confirm Email Home PhoneCell Phone*Work PhoneExtension Additional InformationMarital Status*MarriedSingle ParentDivorcedSeperatedLiving TogetherLanguage*EnglishEnglish/SpanishRace/EthnicityWhiteHispanic or LatinoBlack or African AmericanAsianAmerican Indian or Alaska NativeOtherRent Amount*Landlord's Phone*Monthly Household Income*Please include any government assistance. Please list your children's information below:PLEASE LIST ALL CHILDREN IN YOUR FAMILY FOR OUR RECORDS. ONLY SCHOOL-AGED CHILDREN WILL RECEIVE A BACKPACK (K -12TH). Please specify the grade level each will be in at the start of the 2025-2026 school year.How many of your children will be in PRE-K/KINDERGARTEN beginning September 1st?*How many of your children will be in ELEMENTARY beginning September 1st?*How many of your children will be in JR HIGHSCHOOL beginning September 1st?*How many children are in your Legal Custody?*12345678Child #1* First Last Age*0-12345678910111112131415161718Birth Date* MM slash DD slash YYYY Grade Level (as of Sept 1st)*Pre-K or K1st2nd3rd4th5th6th7th8th9th10th11th12thGender*MaleFemaleChild #2* First Last Age*0-12345678910111112131415161718Birth Date* MM slash DD slash YYYY Grade Level (as of Sept 1st)*Pre-K or K1st2nd3rd4th5th6th7th8th9th10th11th12thGender*MaleFemaleChild #3* First Last Age*0-12345678910111112131415161718Birth Date* MM slash DD slash YYYY Grade Level (as of Sept 1st)*Pre-K or K1st2nd3rd4th5th6th7th8th9th10th11th12thGender*MaleFemaleChild #4* First Last Age*0-12345678910111112131415161718Birth Date* MM slash DD slash YYYY Grade Level (as of Sept 1st)*Pre-K or K1st2nd3rd4th5th6th7th8th9th10th11th12thGender*MaleFemaleChild #5* First Last Age*0-12345678910111112131415161718Birth Date* MM slash DD slash YYYY Grade Level (as of Sept 1st)*Pre-K or K1st2nd3rd4th5th6th7th8th9th10th11th12thGender*MaleFemaleChild #6* First Last Age*0-12345678910111112131415161718Birth Date* MM slash DD slash YYYY Grade Level (as of Sept 1st)*Pre-K or K1st2nd3rd4th5th6th7th8th9th10th11th12thGender*MaleFemaleChild #7* First Last Age*0-12345678910111112131415161718Birth Date* MM slash DD slash YYYY Grade Level (as of Sept 1st)*Pre-K or K1st2nd3rd4th5th6th7th8th9th10th11th12thGender*MaleFemaleChild #8* First Last Age*0-12345678910111112131415161718Birth Date* MM slash DD slash YYYY Grade Level (as of Sept 1st)*Pre-K or K1st2nd3rd4th5th6th7th8th9th10th11th12thGender*MaleFemaleTotal number of Girls in your legal custody between the ages of 0-18Total number of Boys in your legal custody between the ages of 0-18Total number of children ages 0-5 years oldTotal number of children ages 6-12 years oldTotal number of children ages 13-18 years old Please Provide <span style="color:red">ALL</span> of the following information. <span style="color:red">INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.</span>A hand written letter stating your current situation* Drop files here or Select files Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx, Max. file size: 128 MB. A copy of each child’s Birth Certificate and/or proof of guardianship (DO NOT SEND SOCIAL SECURITY CARDS OR PASSPORTS)* Drop files here or Select files Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx, Max. file size: 128 MB. A copy of your valid photo ID* Drop files here or Select files Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx, Max. file size: 128 MB. A copy of your most current electric bill or most current phone bill with your current address.* Drop files here or Select files Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx, Max. file size: 128 MB. A copy of Food Stamps letter, Medicaid letter, or any other form of government assistance* Drop files here or Select files Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx, Max. file size: 128 MB. Waiver & Release of Liability, Assumption of Risk, and Indemnity Agreement*In return for being allowed to participate in ANY of Houston Children’s Charity programs, including any activities incidental to such participation, I hereby voluntarily and knowingly agree to release, indemnify, defend, hold harmless, and covenant not to sue Houston Children’s Charity, and its officers, directors, staff, employees, sub-contractors, sponsors, agents, volunteers, and affiliates for any and all liability, claims, costs, and causes of action, including, but not limited to, any claim arising out of the ordinary negligence of any of the foregoing, that may be made by me, my family, estate, heirs, or assigns for property damage, personal injury, or wrongful death that may be sustained by me arising as a result of my participation in program services offered by Houston Children’s Charity, or while on the premises owned or leased by Houston Children’s Charity. I understand and agree that Houston Children’s Charity is not responsible for any injury or property damage arising out of my participation in the program services, even if caused by Houston Children’s Charity’s ordinary negligence or otherwise. I understand that participation in the program services involves certain risks, including, but not limited to, serious injury and death. Therefore, I assume all risks, including, but not limited to, the risks associated with slipping, falling, tripping, shifting of heavy objects or furniture, loading or unloading vehicles, operation of equipment or tools, or sustaining any type of related injury in connection with my participation with Houston Children’s Charity. I am voluntarily participating in the program services with knowledge of the danger involved and I agree to accept all risks of participation, even if arising from the negligence of others. I am of legal age and am freely and voluntarily signing this agreement without any inducement, assurance, or guarantee being made to me and intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. I have read this WAIVER & RELEASE OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT and understand that by signing this form, I am giving up legal rights and remedies. I agree Captcha Δ
