Child Information Form 2017 Child's Name* First Last Parent/Guardian Email* Gender*MaleFemaleGrade entering in Fall*KindergartenFirstSecondThirdFourthFifthChild's Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920School District*Parent Cell*Zip Code* ZIP / Postal Code School Attending in the Fall*Clothing Sizing and DescriptionsCoat Type*Child SizeAdult SizeCoat Size*4T5T4/5678/1010/1214/1616/1820Adult SmallAdult MediumAdult LargeAdult X-LargeShirt Type*Child SizeAdult SizeShirt Size*45678101214161820Adult SmallAdult MediumAdult LargeAdult X-LargePants Type*Child SizeAdult SizePants Size*45678101214161820Adult SmallAdult MediumAdult LargeAdult X-LargeShoe Type*Child SizeAdult SizeShoe Size*Child 11Child 12Child 13Youth 1Youth 2Youth 3Youth 4Youth 5Adult 6Adult 7Adult 8Adult 9Adult 10Adult 11Adult 12Does the child have difficulty speaking or understanding English?*YesNoWhat language does the child prefer?*Do we need to be aware of any special needs of the child?*What items help the child feel more prepared for starting school?*Does the family rely on the store for most of the child's essentials?*YesNoIf there was not a Back to School! Store how would the family get these items? (choose one)*FamilyFriendsDo withoutOther organizationWhich items is the child most excited about receiving? (choose one)*ShoesCoatPantsShirtSocksUnderwearHatGlovesBackpackSchool SuppliesBooksI REALIZE THAT MY CHILD MUST BE PRESENT TO OBTAIN ANY ITEMS.* I agree By checking the boxes below, my child WILL participate in vision screening or publicity photos:* The child IS allowed to participate in the eye care vision screening. The child IS NOT allowed to participate in the eye care vision screening. The child IS allowed to be in publicity photos. The child IS NOT allowed to be in publicity photos. Parent/Guardian Name*Date Submitted* Agency NameAnnie MaloneBeginning FuturesBeyond HousingBig Brothers Big Sisters of Eastern MissouriBJC Behavioral HealthBurns Recovered Support GroupCalvery ChristianCenterCaring for KidsCathedral at the CrossroadsCentennial Christian ChurchCenter of HopeCity Garden MontessoriCommunity Church of GodCompton Hill MB ChurchCornerstone Center for Early LearningDepartment of Mental HealthEl Bethel Baptist ChurchFaith Baptist ChurchFaith Miracle Temple ChurchFeed My PeopleFellowship Temple Christian ChurchFirst Community Baptist Church of PagedaleGeorge Washington Carver HouseGrandparents as ParentsGreater Mount Vernon ChurchGreater St. Mark Family ChurchInternational Institute of St. LouisJewish Family & Children's ServiceKIPP Victory AcademyKIPP Wisdom AcademyKoch Elementary SchoolLemay Child & Family CenterLessie Bates Davis Neighborhood HouseLift for Life GymLutheran Community CenterMarygroveMidtown Community ServicesMt. Beulah MB ChurchNew Life Fellowship MB ChurchOak Grove MB ChurchOne Hope UnitedOur Fathers HousePointe of SurrenderSalvation ArmySt. Alphonsus Rock ChurchSt. Francis Community Services-SouthsideSt. Philip's Lutheran ChurchSurrender to ChristUniversity CommonsWalnut Park Community OutreachWilliams Temple Church of God in ChristYouth in NeedAgency Contact Email* This iframe contains the logic required to handle Ajax powered Gravity Forms.