Back2School Application

Back 2 School Application

Step 1 of 5

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.
- Copy of your valid photo ID
- A copy of each child’s birth certificate
- A copy of your most current electric bill or most current phone bill with your current address
Upon receipt of COMPLETE application and documentation, you will be eligible for the Back-to-School program. If your contact information changes (phone number or address), please call our office to update your information. By submitting this form you also agree to allow pictures of you and/or your children in any HCC publication.
Contact Information
Name*
First Last
Spouse Name
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Enter Email Confirm Email
Home Phone
Cell Phone*
Work Phone
Extension

Additional Information
Marital Status*
Language*
Rent 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, INCLUDING NON-SCHOOL AGED CHILDREN. ONLY SCHOOL AGED CHILDREN WILL RECEIVE A BACKPACK (K-12TH). Please list the grade level they will be in at the start of the 2020-2021 school year.
How many children are in your Legal Custody?*
Child #1*
First Last
Age*
Birth Date*
Date Format: MM slash DD slash YYYY
Grade Level (as of Sept 1st)*
Gender*
Child #2*
First Last
Age*
Birth Date*
Date Format: MM slash DD slash YYYY
Grade Level (as of Sept 1st)*
Gender*
Child #3*
First Last
Age*
Birth Date*
Date Format: MM slash DD slash YYYY
Grade Level (as of Sept 1st)*
Gender*
Child #4*
First Last
Age*
Birth Date*
Date Format: MM slash DD slash YYYY
Grade Level (as of Sept 1st)*
Gender*
Child #5*
First Last
Age*
Birth Date*
Date Format: MM slash DD slash YYYY
Grade Level (as of Sept 1st)*
Gender*
Child #6*
First Last
Age*
Birth Date*
Date Format: MM slash DD slash YYYY
Grade Level (as of Sept 1st)*
Gender*
Child #7*
First Last
Age*
Birth Date*
Date Format: MM slash DD slash YYYY
Grade Level (as of Sept 1st)*
Gender*
Child #8*
First Last
Age*
Birth Date*
Date Format: MM slash DD slash YYYY
Grade Level (as of Sept 1st)*
Gender*

Please Provide the Following Documents:
A copy of your valid photo ID*
Drop files here or

Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx.
A copy of each child's birth certificate*
Drop files here or

Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx.
A copy of your most current electric bill or most current phone bill with your current address.*
Drop files here or

Accepted file types: jpg, jpeg, pdf, gif, png, doc, docx.

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
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Back 2 School Application

Step 1 of 5

Contact Information

Additional Information

Please list your children's information below:

Please Provide the Following Documents: