2023-2024 Cocoa Packs Enrollment

Welcome to Cocoa Packs!!!  The purpose of Cocoa Packs is to ensure that all children in Derry Township School District AND the surrounding areas are food secure every day of the year. We aim to provide packs to students filled with a variety of nutritious breakfast, lunch, dinner and snack items on the days that there is no access to subsidized food offerings. The information we ask in this enrollment form is in case we have to move to other means of service as we did during the school closures due to COVID.  We also use non-identifying data to apply for grants that help sustain our organization.  No names, addresses, or phone numbers are ever used in our applications for grants. Your information will not be shared with anyone outside of the Cocoa Packs organization.

All children (age 2 to graduation) are eligible for Cocoa Packs.  Derry Township students can bring their packs home each week.
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Email *
By completing this enrollment,  I agree that I will not sell, dump, or give away food or clothing distributed by Cocoa Packs and any unwanted food or clothing will be returned either through the onsite pantry or placed in one of the distribution bins.  I also agree that Cocoa Packs is not responsible for  any illness or allergies as a result of food received through  donations, Food Rescue, or gardens.   Any violation of this agreement  could result in the removal of assistance. *
Parent Last Name *
Parent First Name *
Parent Home Address *
Parent Phone Number *
In what school district do you live (all districts are eligible, even if not listed) *
Total Number of children being enrolled for Cocoa Packs *
DERRY TOWNSHIP ONLY:  How will your children get their packs?
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Child's Last Name (first Child) *
Child's First Name (First Child)
 *
Grade of school age children for the 2023-2024 school year.  Not-yet-school (NYS) age children are 2 yrs old - 5
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Child's Last Name (second Child)
Child's First Name (second Child)
Grade of school age children for the 2023-2024 school year.  Not-yet-school (NYS) age children are 2 yrs old - 5
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Child's Last Name (third Child)
Child's First Name (third Child)
Grade of school age children for the 2023-2024 school year.  Not-yet-school (NYS) age children are 2 yrs old - 5 yrs old.
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Child's Last Name (fourth Child)
Child's First Name (fourth Child)
 Grade of school age children for the 2023-2024 school year.  Not-yet-school (NYS) age children are 2 yrs old - 5 yrs old.
Clear selection
Child's Last Name (fifth Child)
Child's First Name (fifth Child)
 Grade of school age children for the 2023-2024 school year.  Not-yet-school (NYS) age children are 2 yrs old - 5 yrs old.
Clear selection
Child's Last Name (sixth Child)
Child's First Name (sixth Child)
Grade of school age children for the 2023-2024 school year.  Not-yet-school (NYS) age children are 2 yrs old - 5 yrs old.
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Child's Last Name (seventh Child)
Child's First Name (seventh Child)
Grade of school age children for the 2023-2024 school year.  Not-yet-school (NYS) age children are 2 yrs old - 5 yrs old.
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Child's Last Name (eighth Child)
Child's First Name (eighth Child)
Grade of school age children for the 2023-2024 school year.  Not-yet-school (NYS) age children are 2 yrs old - 5 yrs old.
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Child's Last Name (ninth Child)
Child's First Name (ninth Child)
Grade of school age children for the 2023-2024 school year.  Not-yet-school (NYS) age children are 2 yrs old - 5 yrs old.
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Child's Last Name (tenth Child)
Child's First Name (tenth Child)
Grade of school age children for the 2023-2024 school year.  Not-yet-school (NYS) age children are 2 yrs old - 5 yrs old.
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