Backpack Buddy Permission Form

Please select your language.

* indicates required fields


Dear Parent/Guardian: 


We would like to offer your student an opportunity to participate in the Houston Food Bank’s Backpack Buddy program. Here is how it works:


  • There is no charge for the food sacks to you or to the student.
  • Every Friday at the school your child attends, your child will receive a sack full of nutritious food for the weekend. The food sacks are distributed as discreetly as possible and contains enough food to serve one child per weekend.
  • Texas Emergency Food Assistance Program (TEFAP) products comprise a significant percentage of the food sacks that are distributed to the Backpack Buddy participants. *
  • Houston Food Bank staff will verify free and reduced lunch status of your student on Backpack Buddy Program during school visits.

The Houston Food Bank respects your information and wants to make sure it remains private. This survey will only be used to enroll children in the Backpack Buddy Program. Any data collected will not report individual-level information.





Please enter format MM/DD/YYYY







**Standard data fees & text messaging rates may apply based on your plan with your mobile carrier.

I authorize  [Proxy's name] to be my proxy in the Backpack Buddy program.  Authorization valid for 1 (one) year.






If household is eligible for household crisis food needs, document reasons for crisis here.


Information for Each Child You Wish to Enroll In The Program.



Please enter format MM/DD/YYYY






Click the link just up to the right to enroll another child........


If eligible, would you be willing to share about your experience participating in this program with a Houston Food Bank representative?  

*TEFAP rights and responsibilities are as follows:

Standards for participation in the Program are the same for everyone regardless of race, color, national origin, age, sex, or disability.  You may appeal any decision made by the local agency regarding your denial or termination from the Program.  If your application is approved, the local agency will make nutrition education available to you.

  • By signing below,

    I certify that:

    (1) I am a member of the household living at the address provided in Section 1 and that, on behalf of the household, I apply for USDA Foods that are distributed through The Emergency Food Assistance Program;

    (2) all information provided to the agency determining my household’s eligibility is, to the best of my knowledge and belief, true and correct; and

    (3) if applicable, the information provided by the household’s proxy is, to the best of my knowledge and belief, true and correct.

 

  • By typing my name below, I, as the student(s)' parent/guardian, grant the Houston Food Bank staff and/or certified volunteers permission to verify my student’s school enrollment status from supporting documents. I grant permission for the school personnel to verify my student(s)’ Free and Reduced Lunch status to the Houston Food Bank staff and/or certified volunteers.  I certify that I have read the permission slip in its entirety for the Backpack Buddy Program and would like my student(s) to participate unless I provide verbal or written consent to the school staff to discontinue.  I understand that the food and backpacks cannot be sold or used for other purposes.  I understand that providing my contact information below is optional to participate in community research and story collection conducted by Houston Food Bank.  Any reports produced with the data collected will not identify individual information.  I understand that I will not be denied for services if I wish to not provide contact information. I understand my rights and responsibilities as stated above.
Please type your name below as an electronic signature confirming your agreement and understanding of this form.