Christmas Assistance Application Form

Head of Household

First NameMiddle NameLast Name

Date of Birth

MM-DD-YYYY

Gender

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.Format: (000) 000-0000.

Number of people in your home:

Type number

1st Name (not head of household):

First NameLast Name

Date of Birth

Date

Relationship to you:

Type spouse, partner, parent, child, or other

2nd Name:

First NameLast Name

Date of Birth

Date

Relationship to you:

Type spouse, partner, parent, child, or other

3rd Name:

First NameLast Name

Date of Birth

Date

Relationship to you:

Type spouse, partner, parent, child, or other

4th Name:

First NameLast Name

Date of Birth

Date

Relationship to you:

Type spouse, partner, parent, child, or other

First Child: Name

First NameLast Name

Date of Birth

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

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

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

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

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

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

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 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 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 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

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.

Other

Upload copies of IDs, updated income and expenses we do not have

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 our church after the Holidays? (this has no effect on your application) Yes No

Would you like information in the spring on sending your child to a sleep-away camp in the summer? Yes No

Christmas Assistance Application, 2023