Register for Assistance

New or existing family?

School your children attend (Check all that apply) :

Children Under the Age of 5 Ocean Road Elementary School Nellie Bennett Elementary School Memorial Middle School Point Pleasant High School

Guardian/Parent name :

Address :

City :

State :

Zip :

Phone :

E-mail :

How many children do you have living with you? (Only children under 18)

Child 1 -----------------------------------------------------------------------------------------------------------------------

Name :

Age :

Gender :

School :

Teacher :

Child 2 ----------------------------------------------------------------------------------------------------------------------

Name :

Age :

Gender :

School :

Teacher :

Child 3 ----------------------------------------------------------------------------------------------------------------------

Name :

Age :

Gender :

School :

Teacher :

Child 4 -----------------------------------------------------------------------------------------------------------------------

Name :

Age :

Gender :

School :

Teacher :

Child 5 --------------------------------------------------------------------------------------------------------------------

Name :

Age :

Gender :

School :

Teacher :

Child 6 ---------------------------------------------------------------------------------------------------------------------

Name :

Age :

Gender :

School :

Teacher :

*Anyone over the age of 18 will be provided information to receive food from the local Food Pantry

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