OnLine Application

Detroit Goodfellow Application

Apply for the 2020 Program
Please be assured that your information will be held in strict confidence and will not be shared with any other organization or agency
Who is filling out this form? *

Mother Father Guardian
Your Email *

Confirmation Email
Mother's Full Name

First Name Last Name
Father's Full Name

First Name Last Name
Guardian's Full Name

First Name Last Name
Your Address (this is where your confirmation letter will be sent) *

Street Address

Address Continued

City State

ZIP
Your Cell Phone *

Area Code Phone Number
Please provide the child(ren)'s full name, Gender, Birthdate and MI Health Number. Only Children born between January 1, 2007 and December 31, 2016 will be eligible to receive packages. You can apply for up to eight (8) children on this application. When finished, be sure to click the Submit button at the bottom. By clicking Submit, you agree that the Goodfellows may contact you by email or text.
1st Child's Full Name *

First Name Last Name
Gender *

Boy Girl
Birth Date *

Month Day Year
MI Health No. *
Another Child? *

Yes No
2nd Child's Full Name

First Name Last Name
Gender

Boy Girl
Birth Date

Month Day Year
MI Health No.
Another Child?

Yes No
3rd Child's Full Name

First Name Last Name
Gender

Boy Girl
Birth Date

Month Day Year
MI Health No.
Another Child?

Yes No
4th Child's Full Name

First Name Last Name
Gender

Boy Girl
Birth Date

Month Day Year
MI Health No.
Another Child?

Yes No
5th Child's Full Name

First Name Last Name
Gender

Boy Girl
Birth Date

Month Day Year
MI Health No.
Another Child?

Yes No
6th Child's Full Name

First Name Last Name
Gender

Boy Girl
Birth Date

Month Day Year
MI Health No.
Another Child?

Yes No
7th Child's Full Name

First Name Last Name
Gender

Boy Girl
Birth Date

Month Day Year
MI Health No.
Another Child?

Yes No
8th Child's Full Name

First Name Last Name
Gender

Boy Girl
Birth Date

Month Day Year
MI Health No.
Should be Empty:

Detroit Goodfellow Application