As the Head of the Household, I agree to participate in the Power Packs Project and will consistently pick up my families' Power Pack at the distribution site and time checked below.

I agree to check each of the items in the Pack carefully to ensure that all the food is safe and appropriate for my family and to refrigerate the food that must be kept cold.  If I am unable to pick up my family's Power Pack distribution, I will find a family member or friend to do so.  I understand that if my family's distribution is not picked up and I do not notify REAL Life Community Services in advance, on two consecutive distribution days or a total of four distribution days during the school year, I may no longer be eligible to participate.   I am committed to improving my family's future and agree to use the weekly Recipes and Tips provided by the Project, storing them in the folder provided for future reference.  I understand that delivery is not an option.

TOTAL Household Income (must be at or lower than these amounts to qualify for Power Packs program)

Household size     Annual     Monthly     Weekly
1 person              $27,861   $2,322       $  536
2 people              $37,814   $3,151       $  728
3 people              $47,767   $3,981       $  919
4 people              $57,720   $4,810       $1,110
5 people              $67,673   $5,640       $1,302
6 people              $77,626   $6,469       $1,493
7 people              $87,579   $7,299       $1,685
8 people              $97,532   $8,128       $1,876
add'l people             9,953       830            192 per person

Please list first and last name for every person living in your house and their birthdates.  List school attended for each child under 18.