Claromentis - Submit ticket - Backpack Buddy Online Referral Form 2023-2024 (English)

1. School Name*

2. School District*

Other School District

3. Student Name*

4. Age

5. Grade

6. Teacher

7. Food Insecurity Behavior (At least 1 must be selected; Select all that apply)

Rushing Food Lines

Extreme hunger on Monday morning

Quickly eating all the food served and asking for more

Asking when the next snack/meal will be

Saving/hoarding/stealing food to take home for themselves and/or siblings

Lingering around for or asking for seconds

Comments about not having enough food at home

Asking Classmates fro food they don't want

Chronic stomach aches

8. Physical Appearance (Check all that apply)

Extreme Thinness

Puffy, Swollen Skin

Chronically dry, cracked lips

Chronically dry, itchy eyes

Brittle, spoon-shaped nails

9. School Performance (Check all that apply)

Excessive absences and/or tardiness

Repetition of a grade

Chronic sickness

Short attention span/inability to concentrate

Chronic behavior that leads to disciplinary action (Hyperactive, aggressive, irritable, anxious, withdrawn, distressed, passive/aggressive)

Parents scheduling medical appointments until after lunch

10. Home Environment (check all that apply)

Often cooking their own meals, or has a sibling who does

Frequent moves

Often spends night away from home (primary residence)

Loss of income

Family crisis

Parent referral/request

11. Are there other school-aged children in this household?

Yes

No

12. If so, how many?

13. Is the student (or student family) any of the following programs?

Supplemental Nutrition Assistance Program (SNAP)?

School Free & Reduced Lunch Program?

Medicaid / Childrens Health Insurance Program (CHIP)?

Social Security Income (SSI)?

Temporary Assistance for Needy Families (TANF)?

14. Has this family ever used any of Houston Food Bank’s other programs that you are aware of, including

Visited a pantry that is an HFB Partner?

Community Assistance Program?

Community Kitchen (Culinary training program)?

Nutrition Education classes?

Portwall Pantry (HFB Pantry)?

School Market (Pantries/Markets located at schools)?

Kids Café (Free after-school and summer meals)?

I have never used any other service

I’m not sure

15. If eligible, would you be willing to share about your experience participating in this program with a Houston Food Bank representative? (Please note that this is completely optional and will not affect your eligibility for this program)

Yes

No

Parent Referral (If Parent Is self referring kid)

16. Name/Title of person referring student

18. Name of School Coordinator*

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