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Assistance Application
Your Information
First Name
*
Last Name
*
Phone
*
Are you referring your family or another family?
*
My Family
Another Family
The Family we can assist
Street Address
*
Apartment, suite, etc
City
*
Select
Eielson
Fairbanks
Nenana
North Pole
Salsha
Wainwright
Email
Phone
*
For the family you are referring
Special directions to locate the home
Is the family receiving services from other non-profits?
*
Salvation Army
Love INC
Other
None
Please specify
*
Did this family receive assistance from Santa's Helpers last year?
*
Yes
No
Not sure
Do you need food boxes?
*
Yes
No
Please indicate ALL people living in the household listing ADULTS FIRST, including the applicant if you are referring your own family
How many people are living in the household?
*
Select
1
2
3
4
5
6
7
8
9
10
Including applicant
First Name
*
Last Name
*
Age
*
Select
Adult
Gender
*
Select
Female
Male
Family Title
*
Select
Mom
Dad
Grandparent
Son
Daughter
Other
Please Specify
*
First Name
*
Last Name
*
Age
*
Select
Adult
Newborn
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Gender
*
Select
Female
Male
Family Title
*
Select
Mom
Dad
Grandparent
Son
Daughter
Other
Please Specify
*
First Name
*
Last Name
*
Age
*
Select
Adult
Newborn
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Gender
*
Select
Female
Male
Family Title
*
Select
Mom
Dad
Grandparent
Son
Daughter
Other
Please Specify
*
First Name
*
Last Name
*
Age
*
Select
Adult
Newborn
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Gender
*
Select
Female
Male
Family Title
*
Select
Mom
Dad
Grandparent
Son
Daughter
Other
Please Specify
*
First Name
*
Last Name
*
Age
*
Select
Adult
Newborn
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Gender
*
Select
Female
Male
Family Title
*
Select
Mom
Dad
Grandparent
Son
Daughter
Other
Please Specify
*
First Name
*
Last Name
*
Age
*
Select
Adult
Newborn
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Gender
*
Select
Female
Male
Family Title
*
Select
Mom
Dad
Grandparent
Son
Daughter
Other
Please Specify
*
First Name
*
Last Name
*
Age
*
Select
Adult
Newborn
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Gender
*
Select
Female
Male
Family Title
*
Select
Mom
Dad
Grandparent
Son
Daughter
Other
Please Specify
*
First Name
*
Last Name
*
Age
*
Select
Adult
Newborn
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Gender
*
Select
Female
Male
Family Title
*
Select
Mom
Dad
Grandparent
Son
Daughter
Other
Please Specify
*
First Name
*
Last Name
*
Age
*
Select
Adult
Newborn
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Gender
*
Select
Female
Male
Family Title
*
Select
Mom
Dad
Grandparent
Son
Daughter
Other
Please Specify
*
First Name
*
Last Name
*
Age
*
Select
Adult
Newborn
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Gender
*
Select
Female
Male
Family Title
*
Select
Mom
Dad
Grandparent
Son
Daughter
Other
Please Specify
*
Does the child(ren) have a bike(s)?
*
Yes
No
Unsure
Do you currently have a child with special needs that is living in the household of the family you are applying for?
*
Yes
No
Unsure
Tell us your child's special needs for play
*
Reference
First Name
*
Last Name
*
Phone
*
Anything else you want to share?
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