Christmas Assistance Application Form

COHAP Christmas Assistance Application

Fill out the form carefully for registration
Head of Household*

First NameMiddle NameLast Name
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
Children in Home (12 and under)

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

First NameLast Name
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
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
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
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
Age:
Boy or Girl?
Type Boy or Girl
Please share your child’s wish list.
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
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
Have you received help from Center of Hope & Peace?*
How did you hear about COHAP?*
By submitting this application, you confirm that, to the best of your knowledge, all the information provided is accurate and verifiably true. You also give COHAP permission to verify any of this information.
Should be Empty:

COHAP Christmas Assistance Application

Children in Home (12 and under)