Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
P.C.O.M
Linking Idividuals and Families to Resources and Oppurtunities!!
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County-Municipality
*
Name of Child:
*
First Name
Last Name
Age
Gender
Name of Child:
First Name
Last Name
Age
Gender
Name of Child:
First Name
Last Name
Age
Gender
Name of Child:
First Name
Last Name
Age
Gender
Name of Child:
First Name
Last Name
Age
Gender
Name of Child:
First Name
Last Name
Age
Gender
Name of Child:
First Name
Last Name
Age
Gender
Name of Child:
First Name
Last Name
Age
Gender
Name of Child:
First Name
Last Name
Age
Gender
Name of Child:
First Name
Last Name
Age
Gender
List any special needs for the children listed above.
Please choose one of the following of which you are recommending as a client with P.C.O.M for the Holiday Outreach Initiative.
*
Myself
A friend/ neighbor
Other
How many ADULTS in the home 18 or older?
*
How many CHILDREN in the home under the age 18?
*
Please select one of the following to explain income status.
*
Employed
Unemployed
Fixed Income
Other
Disability
Does anyone receive government funded resources (SNAP/EBT, Welfare, WIC, Medicaid, etc)
*
Yes
No
Did you apply to other organizations to receive assistance for Christmas? If so did you get denied?
*
This space is provided for you to share with us any additional information you would like for us to know about your current situation.
*
Disclaimer
*
Submit
Name
*
First Name
Last Name
Should be Empty: