School Supplies Application

--Zip Code--28079 28104 28105 28226 28270

Have you or a household member received services from Matthews HELP Center? --Please Select--Yes No

Date of Birth:

--Type of Photo ID--Drivers License ID Card Passport --State of ID--AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

--Gender--Female Male --Race/Ethnicity--American Indian / Alaskan Native Asian / Pacific Islander Black or African American Hispanic Multiple Ethnicity / Other White / Caucasian Decline

--Highest Level of Education Completed--Less than high school degree High school degree or equivalent (e.g., GED) Some college but no degree Trade School Associate degree Bachelor degree Graduate degree N/A Minor Child --Employment Status--Disabled Employed (Full-Time) Employed (Part-Time) Employed, 2+ Jobs Retired Self-Employed Unemployed Temporary / Contract Student N/A Minor Child

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.