Christmas Assistance Application Form

Heavens Care Christmas Assistance Application (2022)

Fill out the form carefully for registration
Head of Household*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
MM-DD-YYYY
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:*

Confirmation Emailexample@example.com
Phone Number*
Please enter a valid phone number.
Number of people in your home:
Type number
Adults and Children over 12 in Home
1st Name (not head of household):

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to you:
Type spouse, partner, parent, child, or other
2nd Name:

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to you:
Type spouse, partner, parent, child, or other
3rd Name:

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to you:
Type spouse, partner, parent, child, or other
4th Name:

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to you:
Type spouse, partner, parent, child, or other
Children in Home (12 and under)

Fill out information for each child in your home
First Child: Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age:*
Boy or Girl?*
Type Boy or Girl
Wish #1:
Type First Wish
Wish #2:
Type Second Wish
Wish #3:
Type Third Wish
Clothing Size (please indicate if it is children's size or adult size):
Type Size
Shoe Size (please indicate if it is children's size or adult size):
Type Size
2nd Child: Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age:
Boy or Girl?
Type Boy or Girl
Wish #1:
Type First Wish
Wish #2:
Type Second Wish
Wish #3:
Type Third Wish
Clothing Size (please indicate if it is children's size or adult size):
Type Clothing Size
Shoe Size (please indicate if it is children's size or adult size):
Type Shoe Size
3rd Child: Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age:
Boy or Girl?
Type Boy or Girl
Wish #1:
Type First Wish
Wish #2:
Type Second Wish
Wish #3:
Type Third Wish
Clothing Size (please indicate if it is children's size or adult size):
Type Clothing Size
Shoe Size (please indicate if it is children's size or adult size):
Type Shoe Size
4th Child: Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age:
Boy or Girl?
Type Boy or Girl
Wish #1:
Type First Wish
Wish #2:
Type Second Wish
Wish #3:
Type Third Wish
Clothing Size (please indicate if it is children's size or adult size):
Type Clothing Size
Shoe Size (please indicate if it is children's size or adult size):
Type Shoe Size
5th Child: Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age:
Boy or Girl?
Type Boy or Girl
Wish #1:
Type First Wish
Wish #2:
Type Second Wish
Wish #3:
Type Third Wish
Clothing Size (please indicate if it is children's size or adult size):
Type Clothing Size
Shoe Size (please indicate if it is children's size or adult size):
Type Shoe Size
6th Child: Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age:
Boy or Girl?
Type Boy or Girl
Wish #1:
Type First Wish
Wish #2:
Type Second Wish
Wish #3:
Type Third Wish
Clothing Size (please indicate if it is children's size or adult size):
Type Clothing Size
Shoe Size (please indicate if it is children's size or adult size):
Type Shoe Size
Monthly Income:

Must be filled out for everyone working in the family
Income for Head of Household*

First NameLast Name
Fill in all blanks. If not applicable, enter '0'
Amount received in Salary Monthly:
Type Amount
Amount received in Public Assistance Monthly:
Type Amount
Amount Received in Food Stamps Monthly:
Type Amount
Amount of rent paid by Section 8 Monthly:
Type Amount
Amount of Social Security Received Monthly:
Type Amount
Amount of SSI/SSD Received Monthly:
Type Amount
Amount of Pension Received Monthly:
Type Amount
Amount of Unemployment Received Monthly:
Type Amount
Amount of Child Support Received Monthly:
Type Amount
Other Income Received Monthly:
Type amount and give explanation - or put n/a
Other Income Received Monthly:
Type amount and give explanation - or put n/a
Income for 2nd Adult in Family:

First NameLast Name
Fill in all blanks. If not applicable, enter '0'
Amount received in Salary Monthly:
Type Amount
Amount received in Public Assistance Monthly:
Type Amount
Amount Received in Food Stamps Monthly:
Type Amount
Amount of rent paid by Section 8 Monthly:
Type Amount
Amount of Social Security Received Monthly:
Type Amount
Amount of SSI/SSD Received Monthly:
Type Amount
Amount of Pension Received Monthly:
Type Amount
Amount of Unemployment Received Monthly:
Type Amount
Amount of Child Support Received Monthly:
Type Amount
Other Income Received Monthly:
Type amount and explanation or put n/a
Other Income Received Monthly:
Type amount and explanation or put n/a
Income for 3rd Adult in Family:

First NameLast Name
Fill in all blanks. If not applicable, enter '0
Amount received in Salary Monthly:
Type Amount
Amount received in Public Assistance Monthly:
Type Amount
Amount Received in Food Stamps Monthly:
Type Amount
Amount of rent paid by Section 8 Monthly:
Type Amount
Amount of Social Security Received Monthly:
Type Amount
Amount of SSI/SSD Received Monthly:
Type Amount
Amount of Pension Received Monthly:
Type Amount
Amount of Unemployment Received Monthly:
Type Amount
Amount of Child Support Received Monthly:
Type Amount
Other Income Received Monthly:
Type amount and explanation or put n/a
Other Income Received Monthly:
Type amount and explanation or put n/a
Total Household Monthly Expenses:
Fill in all blanks. If not applicable, enter '0'
Rent/Mortgage:
Type Amount
Gas/Heat/Oil:
Type Amount
Electricity:
Cable/Internet:
Type Amount
Phone
Type Amount
Car Payment:
Type Amount
Car Insurance:
Type Amount
Other Monthly Expenses
Type amount and explanation or put n/a
Other Monthly Expenses
Type amount and explanation or put n/a
Have you previously submitted copies of all ID's for those in your family, as well as proof of all income and expense? If not, you may be asked to do so before your application can be processed.*

I have already submitted copiesI'm not sure if I have. Can you call me and let me know?My income and/or expenses have changed since last year. Upload updated information belowI have not submitted copies. Upload information belowOther
Upload copies of IDs, updated income and expenses we do not have

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Have you received help from Heavens Care at Christmas before?*
Are you going to request assistance from anywhere else?*
Do you attend church regularly? (this has no effect on your application)*
If your answer was yes, which church do you attend?Insert Church Name
Would you like a visit from Heavens Care after the Holidays? (this has no effect on your application) YesNo*
By submitting this application, you confirm that, to the best of your knowledge, all the informatin provided is accurate and verifiably true. You also give Heavens Care permission to verify any of this information. Please understand that if you are being helped by another agency in town, you might not also be helped by Heavens Care.
Should be Empty:

Heavens Care Christmas Assistance Application (2022)

Adults and Children over 12 in Home

Children in Home (12 and under)

Monthly Income:

Total Household Monthly Expenses: