Floyd County Back Pack Program

Please enable JavaScript in your browser to complete this form.

– Step 1 of 6

Student's Name *

First

Last

School *

School Bus #

Current Grade *

Allergies or Prohibited Foods

Student's Name

First

Last

School

School Bus #

Current Grade

Allergies or Prohibited Foods

Student's Name

First

Last

School

School Bus #

Current Grade

Allergies or Prohibited Foods

Student's Name

First

Last

School

School Bus #

Current Grade

Allergies or Prohibited Foods

Student's Name

First

Last

School

School Bus #

Current Grade

Allergies or Prohibited Foods

Today's Date *

Head of Household Name *

First

Last

Home Phone

Cell Phone

Emergency/Message Phone

Physical Street Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address same as physical *

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Benefits *

SNAP
WIC
Child Support
Housing Choice Voucher
Low-income Housing

Family Type *

Single Parent Female
Two Parent Household
Non-Related Adults+Children
Single Parent Male
Multigenerational
Other

Specify if Other

Housing TStatus *

Renting/Leasing
Homeowner (w/mortgage)
Homeowner (no mortgage)
Homeless (tent, street, place not meant for habitation)
Community Shelter
Hotel/Motel Room (who paid?)
Unstable Housing/At-risk of losing (doubled up, couch-surfing, unlawful detainer, 5 day pay or quit)
Imminently losing housing (FC, jail/prison, MH treatment, hospital, SA recovery, nursing home)
Other

Specify *

How many members are in the household *

Head of Household
2
3
4
5
6
7
8
9
10

Please include all people living in the household, including yourself, the students, any other dependents, and spouse or domestic partner.

Head of Household Demographics

The demographic information collected here is used for reporting to various funding sources only. Income is the only item used to determine program eligibility.

Name – Head of Household *

First

Middle

Last

Language-Head of Household *

English
Spanish
Other

Gender-Head of Household *

Male
Female
Other

Date of Birth-Head of Household *

Currently Enrolled in School – Head of Household *

Education Level – Head of Household *

Grades 0-8
Grades 9-12/Non-Graduate
High School Graduate
GED/Equivalency Diploma
12 grade + Some Post-Secondary
2 or 4 years College Graduate
Graduate of other post-secondary school

Health Insurance – Head of Household *

Direct Purchase: Private
Medicare
Medicaid
None
Premier
FAMIS (Virginia CHIP)
Military
Virginia Adult
Employer

Race – Head of Household *

American Indian/Alaskan Native
Asian
Black or African American
Hawaiian or Pacific Islander
White
Multi-race
Other

Hispanic, Latino, Spanish-Head of Household *

Disability- Head of Household *

Mental
Physical
Substance
None

Military Status- Head of Household *

Active
Veteran
Not a Vet

Work Status – Head of Household *

Full Time
Part Time
Migrant Seasonal Worker
Unemployed less than 6 months
Unemployed more than 6 months
Unemployed (not in labor force)
Retired

Income Source: Head of Household *

Wages
Self Employed
Social Security
SSI/SSDI
TANF
EADC
Unemployment
Veterans Benefits
Pension
Workers Comp
Interest/Dividends
Rental Income
Child Support
Other
No Income

Total Monthly Income *

—————————————————————————————————————————————

Demographics for Household Member 2

The demographic information collected here is used for reporting to various funding sources only. Income is the only item used to determine program eligibility.

Name – Household Member 2 *

First

Middle

Last

Language- Household Member 2 *

English
Spanish
Other

Gender-Household Member 2 *

Male
Female
Other

Date of Birth-Member 2 *

Currently Enrolled in School -Member 2 *

Education Level – Member 2 *

Grades 0-8
Grades 9-12/Non-Graduate
High School Graduate
GED/Equivalency Diploma
12 grade + Some Post-Secondary
2 or 4 years College Graduate
Graduate of other post-secondary school

Health Insurance – Household Member 2 *

Direct Purchase: Private
Medicare
Medicaid
None
Premier
FAMIS (Virginia CHIP)
Military
Virginia Adult
Employer

Race – Member 2 *

American Indian/Alaskan Native
Asian
Black or African American
Hawaiian or Pacific Islander
White
Multi-race
Other

Hispanic, Latino, Spanish Member 2 *

Disability- Member 2 *

Mental
Physical
Substance
None

Military Status- Member 2 *

Active
Veteran
Not a Vet

Work Status -Household Member 2 *

Full Time
Part Time
Migrant Seasonal Worker
Unemployed less than 6 months
Unemployed more than 6 months
Unemployed (not in labor force)
Retired

Income Source: Household Member 2 *

Wages
Self Employed
Social Security
SSI/SSDI
TANF
EADC
Unemployment
Veterans Benefits
Pension
Workers Comp
Interest/Dividends
Rental Income
Child Support
Other
No Income

Total Monthly Income (if applicable) *

—————————————————————————————————————————————

Demographics for Household Member 3

The demographic information collected here is used for reporting to various funding sources only. Income is the only item used to determine program eligibility.

Name – Household Member 3 *

First

Middle

Last

Language- Household Member 3 *

English
Spanish
Other

Gender-Household Member 3 *

Male
Female
Other

Date of Birth-Member 3 *

Currently Enrolled in School – Member 3 *

Education Level – Member 3 *

Grades 0-8
Grades 9-12/Non-Graduate
High School Graduate
GED/Equivalency Diploma
12 grade + Some Post-Secondary
2 or 4 years College Graduate
Graduate of other post-secondary school

Health Insurance – Household Member 3 *

Direct Purchase: Private
Medicare
Medicaid
None
Premier
FAMIS (Virginia CHIP)
Military
Virginia Adult
Employer

Race – Member 3 *

American Indian/Alaskan Native
Asian
Black or African American
Hawaiian or Pacific Islander
White
Multi-race
Other

Hispanic, Latino, Spanish Member 3 *

Disability- Member 3 *

Mental
Physical
Substance
None

Military Status- Member 3 *

Active
Veteran
Not a Vet

Work Status -Household Member 3 *

Full Time
Part Time
Migrant Seasonal Worker
Unemployed less than 6 months
Unemployed more than 6 months
Unemployed (not in labor force)
Retired

Income Source: Household Member 3 *

Wages
Self Employed
Social Security
SSI/SSDI
TANF
EADC
Unemployment
Veterans Benefits
Pension
Workers Comp
Interest/Dividends
Rental Income
Child Support
Other
No Income

Total Monthly Income Member 3 (if applicable) *

—————————————————————————————————————————————

Demographics for Household Member 4

The demographic information collected here is used for reporting to various funding sources only. Income is the only item used to determine program eligibility.

Name – Household Member 4 *

First

Middle

Last

Language- Household Member 4 *

English
Spanish
Other

Gender-Household Member 4 *

Male
Female
Other

Date of Birth-Member 4 *

Currently Enrolled in School – Member 4 *

Education Level – Member 4 *

Grades 0-8
Grades 9-12/Non-Graduate
High School Graduate
GED/Equivalency Diploma
12 grade + Some Post-Secondary
2 or 4 years College Graduate
Graduate of other post-secondary school

Health Insurance – Household Member 4 *

Direct Purchase: Private
Medicare
Medicaid
None
Premier
FAMIS (Virginia CHIP)
Military
Virginia Adult
Employer

Race – Member 4 *

American Indian/Alaskan Native
Asian
Black or African American
Hawaiian or Pacific Islander
White
Multi-race
Other

Hispanic, Latino, Spanish Member 4 *

Disability- Member 4 *

Mental
Physical
Substance
None

Military Status- Member 4 *

Active
Veteran
Not a Vet

Work Status -Household Member 4 *

Full Time
Part Time
Migrant Seasonal Worker
Unemployed less than 6 months
Unemployed more than 6 months
Unemployed (not in labor force)
Retired

Income Source: Household Member 4 *

Wages
Self Employed
Social Security
SSI/SSDI
TANF
EADC
Unemployment
Veterans Benefits
Pension
Workers Comp
Interest/Dividends
Rental Income
Child Support
Other
No Income

Total Monthly Income Member 4 (if applicable) *

—————————————————————————————————————————————

Demographics for Household Member 5

The demographic information collected here is used for reporting to various funding sources only. Income is the only item used to determine program eligibility.

Name – Household Member 5 *

First

Middle

Last

Language- Household Member 5 *

English
Spanish
Other

Gender-Household Member 5 *

Male
Female
Other

Date of Birth-Member 5 *

Currently Enrolled in School – Member 5 *

Education Level – Member 5 *

Grades 0-8
Grades 9-12/Non-Graduate
High School Graduate
GED/Equivalency Diploma
12 grade + Some Post-Secondary
2 or 4 years College Graduate
Graduate of other post-secondary school

Health Insurance – Household Member 5 *

Direct Purchase: Private
Medicare
Medicaid
None
Premier
FAMIS (Virginia CHIP)
Military
Virginia Adult
Employer

Race – Member 5 *

American Indian/Alaskan Native
Asian
Black or African American
Hawaiian or Pacific Islander
White
Multi-race
Other

Hispanic, Latino, Spanish Member 5 *

Disability- Member 5 *

Mental
Physical
Substance
None

Military Status- Member 5 *

Active
Veteran
Not a Vet

Work Status -Household Member 5 *

Full Time
Part Time
Migrant Seasonal Worker
Unemployed less than 6 months
Unemployed more than 6 months
Unemployed (not in labor force)
Retired

Income Source: Household Member 5 *

Wages
Self Employed
Social Security
SSI/SSDI
TANF
EADC
Unemployment
Veterans Benefits
Pension
Workers Comp
Interest/Dividends
Rental Income
Child Support
Other
No Income

Total Monthly Income Member 5 (if applicable) 5 *

—————————————————————————————————————————————

Demographics for Household Member 6

The demographic information collected here is used for reporting to various funding sources only. Income is the only item used to determine program eligibility.

Name – Household Member 6 *

First

Middle

Last

Language- Household Member 6 *

English
Spanish
Other

Gender-Household Member 6 *

Male
Female
Other

Date of Birth-Member 6 *

Currently Enrolled in School – Member 6 *

Education Level – Member 6 *

Grades 0-8
Grades 9-12/Non-Graduate
High School Graduate
GED/Equivalency Diploma
12 grade + Some Post-Secondary
2 or 4 years College Graduate
Graduate of other post-secondary school

Health Insurance – Household Member 6 *

Direct Purchase: Private
Medicare
Medicaid
None
Premier
FAMIS (Virginia CHIP)
Military
Virginia Adult
Employer

Race – Member 6 *

American Indian/Alaskan Native
Asian
Black or African American
Hawaiian or Pacific Islander
White
Multi-race
Other

Hispanic, Latino, Spanish Member 6 *

Disability- Member 6 *

Mental
Physical
Substance
None

Military Status- Member 6 *

Active
Veteran
Not a Vet

Work Status -Household Member 6 *

Full Time
Part Time
Migrant Seasonal Worker
Unemployed less than 6 months
Unemployed more than 6 months
Unemployed (not in labor force)
Retired

Income Source: Household Member 6 *

Wages
Self Employed
Social Security
SSI/SSDI
TANF
EADC
Unemployment
Veterans Benefits
Pension
Workers Comp
Interest/Dividends
Rental Income
Child Support
Other
No Income

Total Monthly Income Member 6 (if applicable) *

—————————————————————————————————————————————

Demographics for Household Member 7

The demographic information collected here is used for reporting to various funding sources only. Income is the only item used to determine program eligibility.

Name – Household Member 7 *

First

Middle

Last

Language- Household Member 7 *

English
Spanish
Other

Gender-Household Member 7 *

Male
Female
Other

Date of Birth-Member 7 *

Currently Enrolled in School – Member 7 *

Education Level – Member 7 *

Grades 0-8
Grades 9-12/Non-Graduate
High School Graduate
GED/Equivalency Diploma
12 grade + Some Post-Secondary
2 or 4 years College Graduate
Graduate of other post-secondary school

Health Insurance – Household Member 7 *

Direct Purchase: Private
Medicare
Medicaid
None
Premier
FAMIS (Virginia CHIP)
Military
Virginia Adult
Employer

Race – Member 7 *

American Indian/Alaskan Native
Asian
Black or African American
Hawaiian or Pacific Islander
White
Multi-race
Other

Hispanic, Latino, Spanish Member 7 *

Disability- Member 7 *

Mental
Physical
Substance
None

Military Status- Member 7 *

Active
Veteran
Not a Vet

Work Status -Household Member 7 *

Full Time
Part Time
Migrant Seasonal Worker
Unemployed less than 6 months
Unemployed more than 6 months
Unemployed (not in labor force)
Retired

Income Source: Household Member 7 *

Wages
Self Employed
Social Security
SSI/SSDI
TANF
EADC
Unemployment
Veterans Benefits
Pension
Workers Comp
Interest/Dividends
Rental Income
Child Support
Other
No Income

Total Monthly Income Member 7 (if applicable) *

—————————————————————————————————————————————

Demographics for Household Member 8

The demographic information collected here is used for reporting to various funding sources only. Income is the only item used to determine program eligibility.

Name – Household Member 8 *

First

Middle

Last

Gender-Household Member 8 *

Male
Female
Other

Language- Household Member 8 *

English
Spanish
Other

Date of Birth-Member 8 *

Currently Enrolled in School – Member 8 *

Education Level – Member 8 *

Grades 0-8
Grades 9-12/Non-Graduate
High School Graduate
GED/Equivalency Diploma
12 grade + Some Post-Secondary
2 or 4 years College Graduate
Graduate of other post-secondary school

Health Insurance – Household Member 8 *

Direct Purchase: Private
Medicare
Medicaid
None
Premier
FAMIS (Virginia CHIP)
Military
Virginia Adult
Employer

Race – Member 8 *

American Indian/Alaskan Native
Asian
Black or African American
Hawaiian or Pacific Islander
White
Multi-race
Other

Hispanic, Latino, Spanish Member 8 *

Disability- Member 8 *

Mental
Physical
Substance
None

Military Status- Member 8 *

Active
Veteran
Not a Vet

Work Status -Household Member 8 *

Full Time
Part Time
Migrant Seasonal Worker
Unemployed less than 6 months
Unemployed more than 6 months
Unemployed (not in labor force)
Retired

Income Source: Household Member 8 *

Wages
Self Employed
Social Security
SSI/SSDI
TANF
EADC
Unemployment
Veterans Benefits
Pension
Workers Comp
Interest/Dividends
Rental Income
Child Support
Other
No Income

Total Monthly Income Member 8 (if applicable) *

—————————————————————————————————————————————

Demographics for Household Member 9

The demographic information collected here is used for reporting to various funding sources only. Income is the only item used to determine program eligibility.

Name – Household Member 9 *

First

Middle

Last

Language- Household Member 9 *

English
Spanish
Other

Gender-Household Member 9 *

Male
Female
Other

Date of Birth-Member 9 *

Currently Enrolled in School – Member 9 *

Education Level – Member 9 *

Grades 0-8
Grades 9-12/Non-Graduate
High School Graduate
GED/Equivalency Diploma
12 grade + Some Post-Secondary
2 or 4 years College Graduate
Graduate of other post-secondary school

Health Insurance – Household Member 9 *

Direct Purchase: Private
Medicare
Medicaid
None
Premier
FAMIS (Virginia CHIP)
Military
Virginia Adult
Employer

Race – Member 9 *

American Indian/Alaskan Native
Asian
Black or African American
Hawaiian or Pacific Islander
White
Multi-race
Other

Hispanic, Latino, Spanish Member 9 *

Disability- Member 9 *

Mental
Physical
Substance
None

Military Status- Member 9 *

Active
Veteran
Not a Vet

Work Status -Household Member 9 *

Full Time
Part Time
Migrant Seasonal Worker
Unemployed less than 6 months
Unemployed more than 6 months
Unemployed (not in labor force)
Retired

Income Source: Household Member 9 *

Wages
Self Employed
Social Security
SSI/SSDI
TANF
EADC
Unemployment
Veterans Benefits
Pension
Workers Comp
Interest/Dividends
Rental Income
Child Support
Other
No Income

Total Monthly Income Member 9 (if applicable) *

—————————————————————————————————————————————

Demographics for Household Member 10

The demographic information collected here is used for reporting to various funding sources only. Income is the only item used to determine program eligibility.

Name – Household Member 10 *

First

Middle

Last

Language- Household Member 10 *

English
Spanish
Other

Gender-Household Member 10 *

Male
Female
Other

Date of Birth-Member 10 *

Currently Enrolled in School – Member 10 *

Education Level – Member 10 *

Grades 0-8
Grades 9-12/Non-Graduate
High School Graduate
GED/Equivalency Diploma
12 grade + Some Post-Secondary
2 or 4 years College Graduate
Graduate of other post-secondary school

Health Insurance – Household Member 10 *

Direct Purchase: Private
Medicare
Medicaid
None
Premier
FAMIS (Virginia CHIP)
Military
Virginia Adult
Employer

Race – Member 10 *

American Indian/Alaskan Native
Asian
Black or African American
Hawaiian or Pacific Islander
White
Multi-race
Other

Hispanic, Latino, Spanish Member 10 *

Disability- Member 10 *

Mental
Physical
Substance
None

Military Status- Member 10 *

Active
Veteran
Not a Vet

Work Status -Household Member 10 *

Full Time
Part Time
Migrant Seasonal Worker
Unemployed less than 6 months
Unemployed more than 6 months
Unemployed (not in labor force)
Retired

Income Source: Household Member 10 *

Wages
Self Employed
Social Security
SSI/SSDI
TANF
EADC
Unemployment
Veterans Benefits
Pension
Workers Comp
Interest/Dividends
Rental Income
Child Support
Other
No Income

Total Monthly Income Member 10 (if applicable) *

More than 10?

If you have more than 10 members in your household, please notify your intake worker.

By checking, I hereby apply for assistance and state that: *

I hereby apply for assistance and state that I have provided full and accurate information the best of my ability and have not withheld or given false information. I understand that failure to be truthful may result in my being prosecuted or denied services, and state that I will not misuse the assistance provided. I understand that my information will be entered into NRCA’s database(s) and used for mandatory reporting to funders. NRCA will never share my personal information (name, contact info) with any outside entity without my permission. I understand that NRCA may contact me via email, text, or phone to share services information or to request feedback on services that my household receives.

Type in your name as electronic signature *