Equipment Request Your Name * First Name Last Name Email * Phone * (###) ### #### Zip Code * What other assistance do you/your family currently receive? (Select all that apply) * Supplemental Nutrition Assistance Program (SNAP) Free & Reduced Lunch Program National School Lunch Program (NSLP) Emergency Food Assistance Program (TEFAP) Low Income Home Energy Assistance (LIHEAP) Child Care Assistance Program Women & Infant Children (WIC) The Head Start Program Medicaid or Medical Assistance for Families SunBucks Program NOT APPLICABLE Other Child's Name * Child's Gender Male Female Child's Age * 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 What sport(s) does your child play? * List all applicable Baseball Basketball Football Soccer Softball Track Other What equipment does your child need? * Shoes Clothing Ball Catcher's Gear Baseball/Softball Glove Baseball/Softball Helmet Batting Gloves Mouth Guard Reciever Gloves Hygiene Other How did you hear about us? * Boys & Girls Club Urban Youth Academy Word of Mouth Social Media Previous equipment recipient Other How would receiving this equipment positively effect your child in sport and why? * Do you request a program assistance sponsorship? * We don't currently support a program sponsorship, but we are looking at adding a scholarship program very soon! Yes No Questions or Comments I have read and agree to the Image Consent and Release Statement. I understand I can withdraw my consent at any time. I understand my data will be processed in accordance with the Image Consent and Release Policy * I agree! Thank you! Image Consent and Release Statement
