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Back to School Program Application

Please complete the application below for each eligible child. Applications are due as soon as possible, but no later than July 26, 2023. Once you submit the form, you will receive a copy of the application via email for your records.

As the staff member submitting this form on behalf of your client, you are responsible for picking up your client’s items from the Community Room in the Langhorne office during the week of August 14, 2023. We will notify you when your client’s items are ready.

If you have any questions, please contact Anne Marie Richards at or 215-757-6916, ext. 218. Thank you.

  • Case Manager/Clinician's Information

  • Client's Information

  • First NameLast NameAgeGrade (Fall 2023)Gender