PRISM Backpack Registration

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Please fill out this form for your child(ren) to receive a free backpack from City of Life Church. Children in preschool, elementary, middle school, or high school are eligible.

In order to qualify, you must be a single mother (meaning unmarried, divorced, separated, widowed) and your children must live in your home and be in preschool, elementary school, middle school, or high school. WE ARE NOT ABLE TO ACCEPT REGISTRATIONS SUBMITTED ON BEHALF OF ANOTHER PERSON - EACH SINGLE MOTHER MUST REGISTER ON HER OWN BEHALF.

Pickup is on Sunday, July 30 after our 9:30 am and 11:30 am services.

City of Life Church
2874 E Irlo Bronson Memorial Hwy
Kissimmee FL, 34744

Email *

Your First Name *

Your Last Name *

Street Address *

City, State, Zip *

Phone Number *

Check ALL that apply: *

I am the mother or legal guardian of the children listed below

I am single (never married, divorced, separated, or widowed)

I am not the mother or the legal guardian of the children listed

Required

By typing your name in the blank below, you affirm that you are a single mother. You affirm that you have at least one child under age 18. You understand that if any of the information on this form is found to be false, you will be considered ineligible for participation in the program. *

Type your first, middle and last name as your electronic signature.

Do you attend City of Life Church?

Yes, In-Person

Yes, I attend Church at Home (facebook, youtube, or cityoflife.live)

I do not attend City of Life Church

The following people have my permission to pick up the backpack(s) on my behalf if I am not able to make it on July 30 for pickup. List names:

I am confirming that I will pick up my backpacks on:

Sunday, July 31 at the 9:30 am or 11:30 am service

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