Registration for 2026 | Backpacks for Success
United Way | Hastings & Prince Edward
Name of Parent/Guardian
*
First Name
Last Name
Contact Information
Email
*
Confirmation Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal Code
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Have you participated with Backpacks for Success previously? For statistical purposes only.
*
Yes
No
Choose not to say
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Backpack Selection and Purchasing
Backpack Selection
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( X )
Backpack
Max. 6 per submission
$12.00 CAD
$
12.00
CAD
Quantity
1
2
3
4
5
6
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
If parent/guardian's name and credit card name differ, please re-state the name on the credit/debit card
First Name
Last Name
Other Payment Methods
If you are unable to make a payment through credit or debit, or cannot make a payment at this time, please call us at (613) 962-9531, or speak to us in-person at 55 Harriett St., Belleville.
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Student and Backpack Information
Total ($12.00 per backpack):
Max. 72
Student Name (1)
*
First Name
Last Name
Grade
*
Kindergarten - Grade 3
Grade 4 - Grade 6
Grade 7 - Grade 12
Does your child require a math set and scientific calculator?
*
Yes
No
Would your child benefit from a a pencil grip (it is foam in material and has ridges to aid with hand posture).
*
Yes
No
Preferred backpack type
*
Please Select
Female
Male
Gender Neutral
Student Name (2)
*
First Name
Last Name
Grade
*
Kindergarten - Grade 3
Grade 4 - Grade 6
Grade 7 - Grade 12
Does your child require a math set and scientific calculator?
*
Yes
No
Would your child benefit from a a pencil grip (it is foam in material and has ridges to aid with hand posture).
*
Yes
No
Preferred backpack type
*
Please Select
Female
Male
Gender Neutral
Student Name (3)
*
First Name
Last Name
Grade
*
Kindergarten - Grade 3
Grade 4 - Grade 6
Grade 7 - Grade 12
Does your child require a math set and scientific calculator?
*
Yes
No
Would your child benefit from a a pencil grip (it is foam in material and has ridges to aid with hand posture).
*
Yes
No
Preferred backpack type
*
Please Select
Female
Male
Gender Neutral
Student Name (4)
*
First Name
Last Name
Grade
*
Kindergarten - Grade 3
Grade 4 - Grade 6
Grade 7 - Grade 12
Does your child require a math set and scientific calculator?
*
Yes
No
Would your child benefit from a a pencil grip (it is foam in material and has ridges to aid with hand posture).
*
Yes
No
Preferred backpack type
*
Please Select
Female
Male
Gender Neutral
Student Name (5)
*
First Name
Last Name
Grade
*
Kindergarten - Grade 3
Grade 4 - Grade 6
Grade 7 - Grade 12
Does your child require a math set and scientific calculator?
*
Yes
No
Would your child benefit from a a pencil grip (it is foam in material and has ridges to aid with hand posture).
*
Yes
No
Preferred backpack type
*
Please Select
Female
Male
Gender Neutral
Student Name (6)
*
First Name
Last Name
Grade
*
Kindergarten - Grade 3
Grade 4 - Grade 6
Grade 7 - Grade 12
Do your child require a math set and scientific calculator?
*
Yes
No
Would your child benefit from a a pencil grip (it is foam in material and has ridges to aid with hand posture).
*
Yes
No
Preferred backpack type
*
Please Select
Female
Male
Gender Neutral
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Pick-Up Locations and Schedule
Please select your preferred pick-up location.
*
Please Select
Belleville
Quinte West
Prince Edward County
Deseronto
Central Hastings
North Hastings
*If you cannot make it to this location, please click the most available location to you and call our office at 613-962-9531
Please verify that you are human
*
THIS IS THE END OF THE FORM
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