Application

Please complete one form for your entire family, listing all school-age children. Please add each child in your household, Pre-K through 12th grade, who would like to participate in the Packed Promise program. To add individuals, click the Add Child button.

CHILD INFORMATION

Please list each child in your household, Pre-K through 12th grade, during the current school year.

Child's First Name*

Middle Name

Last Name*

Suffix

Gender*

Birth Date*

Race/Ethnicity (Select all that apply)*

Tribe*

Grade*

School District*

For school district of Other, please provide school district or other information.

HOUSEHOLD INFORMATION

Household size (number living in home)*

Language spoken in the home*

If other, please enter the language spoken in the home.

Household annual income*

Do you receive SNAP, TANF, FDP, MEDICAID (SoonerCare) or is your child in Head Start?*

Check all that apply*

SNAP

TANF

FDP

MEDICAID (SoonerCare)

Child is in Head Start

PARENT / LEGAL GUARDIAN

Primary Contact

First Name*

Middle Name

Last Name*

Suffix

Mailing Address*

Address Line 2

City*

State*

ZIP*

County*

Shipping address same as mailing

UPS Shipping Address*

Address Line 2

City*

State*

ZIP*

County*

Email Address*

Birth Date

Home Phone

Work Phone

Cell Phone*

May we send text messages to your cell phone regarding monthly benefits?

Yes No

Secondary Contact

Full Name

Phone

Email Address

By checking this box you are giving permission to your school district to share the information with Chickasaw Nation Nutrition Services and USDA. In addition, Chickasaw Nation Nutrition Services and USDA may also confirm the following details from student records for each child: age, grade, gender, school attended, race/ethnicity, free or reduced lunch and language.

Pleased be advised that in order to create a Packed Promise account you must agree to the Conditions of Use and Privacy Notice required by Amazon, LLC.

*Required