School Supplies Application

Have you or a household member received services from Matthews HELP Center? --None--Yes No

How many people reside in your household ?

--Gender--Female Male

Date of Birth

--Zip Code--28079 28104 28105 28211 28226 28270

Please indicate the number of students in your household below:

Number of children in your household needing haircuts:

Names and Ages for children needing haircuts:

By checking this box I certify that all information provided as part of this application is true and correct to the best of my knowledge. I am applying on behalf of children who reside in my household for most or all of the school year. I certify that Matthews Gives Back (to School) is the only organization providing this service for my family.