For Agencies

Backpack Program Report

Backpack Program Report

Please submit by the 5th of each month.

Program Contact Information

This form is for the month of:

Backpack Program Name

Your Name:

E-mail Address:

Backpack Program Totals

Total number of sites (schools) served:

NOTE:

Please ENTER A NUMBER ONLY.
Example: If you regularly give out 125 sacks per week, for four weeks, your "sacks distributed" total would be 500 (125x4).

Total number of sacks distributed:

Program Changes

Has your contact person changed?

Yes
No

Please list new contact person here:

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