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Mobile Van Request Form

School/Organization Name

Address

School District (if applicable)

Check One

Private School

Public School

501c3 Organization

First Name - Principal/Administrator

Last Name - Principal/Administrator

Length of time at School/Organization

Phone

Name of Teacher-Liaison

Length of time at School/Organization (In Years)

Grade Taught/Position

Phone

% of Children Receiving Free/Reduced Lunch

# of McKinney-Vento Students (if any)

% of Spanish Speaking Students

Dates School/Organization is in session

Grade Levels Taught/Services

Number of Full-Time Classroom Teachers

Number of Additional Staff - Part Time

Number of Additional Staff - Administration

Number of Students in you School

Number of Classrooms in your School

Do your students wear uniforms? If yes, please describe

Strength of Parent/Teacher Organiztion

Not Strong

Somewhat Strong

Very Strong

Should Enchanted Backpack deliver to your school, please provide details on how the donation of these items would make an impact for your students and teachers. Also, share with us a little bit about your school and the needs of the students:

Are there any items listed that you would not have a need for?

Other than the school you're applying for please provide at least one, or up to three, elementary or middle schools that would qualify for support from Enchanted Backpack, include contact information when possible:

Is your school or district on social media? If yes, please provide handles for Instagram, Facebook and Twitter:

By checking the box and signing below, you acknowledge that your school qualifies for Enchanted Backpack’s Mobile Van Program and agree to follow all guidelines outlined on page one of this agreement. If guidelines are unable to be met, a Mobile Van Delivery from Enchanted Backpack may not be possible.

Your Signature