Test

Santa's Helpers Assistance Application
Are you referring a family or a self referral?

Family Self-Referral
Person referring family contact Information
Name

First

Last
Phone
Family Information
Name

First

Last
Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Country *
Special directions to locate the home?
Did the family receive assistance from Santa's Helpers last year?

Yes No
Is the family receiving services for other Non-profits?

Love INC Salvation Army None
Do you need food boxes?

Yes No
Please indicate ALL people living in the household listing adults first, including the applicant:
Person #1
Name

First

Last
Relationship to Applicant
Age
Gender
Person #2
Name

First

Last
Relationship to Applicant
Age
Gender
Person #3
Name

First

Last
Relationship to Applicant
Age
Gender
Person #4
Name

First

Last
Relationship to Applicant
Age
Gender
Person #5
Name

First

Last
Relationship to Applicant
Age
Gender
Person #6
Name

First

Last
Relationship to Applicant
Age
Gender
Person #7
Name

First

Last
Relationship to Applicant
Age
Gender
Person #8
Name

First

Last
Relationship to Applicant
Age
Gender
Additional notes about the family
Do you currently havea child with special needs that is living in your household or the household of the family you are applying for?
Does you child(ren) have a bike?
Self Referral reference name and phone number. If the family was referred, skip.

First

Last
Phone

Santa's Helpers Assistance Application