VAV Christmas Assistance Application Form

Village Against Violence Christmas Assistance Application, 2023

Fill out the form carefully for registration. Registration Period:The registration period is from December 1st to December 8th. Be sure to mark these dates on your calendar!Residency Requirement:Participants must be residents of Richmond, Henrico, or Chesterfield.Proof of Residency:Please provide a valid ID as proof of residency during the registration process. This can include a driver's license, utility bill, or any official document with your current address.Children's Age Limit:The toy giveaway is for children, and participants must register on behalf of children aged 1 to 12.Two Toys per Child:Each registered child will have the opportunity to choose two toys during the giveaway event.Registration Does Not Guarantee Pickup:While we will do our best to accommodate all registered participants, please understand that registration does not guarantee the availability of toys. Our supplies are limited, and pickups will be on a first-come, first-served basis.Toy Selection Consideration:Keep in mind that the toys available are donations, and we may not be able to fulfill specific child wishes.
Head of Household*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
MM-DD-YYYY
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
Date of Birth*

MonthDayYear
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

MonthDayYear
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

MonthDayYear
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

MonthDayYear
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

MonthDayYear
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

MonthDayYear
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
Monthly Income:

Must be filled out for everyone working in the family
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 Social Security Received 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 give explanation - or put n/a
Total Household Monthly Expenses:
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.*

I have already submitted copiesI'm not sure if I have. Can you call me and let me know?My income and/or expenses have changed since last year. Upload updated information belowI have not submitted copies. Upload information belowOther
Upload copies of IDs, updated income and expenses we do not have

Cancelof
Are you going to request assistance from anywhere else?*
Would you like a courtesy call from our organization after the Holidays? (this has no effect on your application) YesNo
Should be Empty:

Village Against Violence Christmas Assistance Application, 2023

Children in Home (12 and under)

Monthly Income:

Total Household Monthly Expenses: