Client Application

Client Application
Johnson County Christmas Bureau

email: ClientServices@jccb.org

Phone: 913 210 4975 Spanish: 913 210 4427
Office Only
Reminder

MonthDayYear
Date
Approved # in Family
Family Income
Status
Appointment
Date of last Edit

MonthDayYear
Date
The Note below will be included in Emails to the Client. The Commentary below will not be.
Note
Are you a resident of Johnson County, KS ?*

YesNo
How did you hear about Holiday Shop*
Name*

Last NameFirst Name
Middle Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
E-mail

Confirmation Emailexample@example.com
IF APPROVED APPOINTMENT DATE WILL BE SENT VIA EMAIL
Check all that apply

VeteranFood stampsSSI/Kancare
HOUSEHOLD MEMBERS - List yourself and all people in your household that live with you full-time. As you type in a name more boxes will open for more names. List unborn children as "Unborn" in the Last Name box, check Unborn in the Gender box and put "0" in the Age in Years box. Input the age of childrem under 12 months as "0".
(1)

10
Self

Last NameFirst Name
Gender
Age in Years
Relationship

Self
Monthly Income*
Ethnicity(optional)

Asian PacificAfrican American / BlackCaucasian / WhiteHispanic / LatinoNative AmericanBiracialOther
Primary Language

EnglishSpanishOther
Fill in Others in your Household Below

*For each person in your household give the monthly income, including salary, unemployment, child support, alimony, state aid, food stamps, fosterchild subsidies and disability. If you qualify, you will receive an Email with the date and time of your appointment
(2)

10
Name(2)

Last NameFirst Name
Gender(2)
Age in Years(2)
Relationship(2)
Monthly Income(2)
Ethnicity(optional)(2)

Asian PacificAfrican American / BlackCaucasian / WhiteHispanic / LatinoNative AmericanBiracialOther
Full Time In Household (2)

YesNo
(3)

10
Name(3)

Last NameFirst Name
Gender(3)
Age in Years(3)
Relationship(3)
Monthly Income(3)
Ethnicity(optional)(3)

Asian PacificAfrican American / BlackCaucasian / WhiteHispanic / LatinoNative AmericanBiracialOther
Full Time In Household (3)

YesNo
(4)

10
Name(4)

Last NameFirst Name
Gender(4)
Age in Years(4)
Relationship(4)
Monthly Income(4)
Ethnicity(optional)(4)

Asian PacificAfrican American / BlackCaucasian / WhiteHispanic / LatinoNative AmericanBiracialOther
Full Time In Household (4)

YesNo
(5)

10
Name(5)

Last NameFirst Name
Gender(5)
Age in Years(5)
Relationship(5)
Monthly Income(5)
Ethnicity(optional)(5)

Asian PacificAfrican American / BlackCaucasian / WhiteHispanic/LatinoNative AmericanBiracialOther
Full Time In Household (5)

YesNo
(6)

10
Name(6)

Last NameFirst Name
Gender(6)
Age in Years(6)
Relationship(6)
Monthly Income(6)
Ethnicity(optional)(6)

Asian PacificAfrican American / BlackCaucasian / WhiteHispanic/LatinoNative AmericanBiracialOther
Full Time In Household (6)

YesNo
(7)

10
Name(7)

Last NameFirst Name
Gender(7)
Age in Years(7)
Relationship(7)
Monthly Income(7)
Ethnicity(optional)(7)

Asian PacificAfrican American / BlackCaucasian / WhiteHispanic/LatinoNative AmericanBiracialOther
Full Time In Household (7)

YesNo
(8)

10
Name(8)

Last NameFirst Name
Gender(8)
Age in Years(8)
Relationship(8)
Monthly Income(8)
Ethnicity(optional)(8)

Asian PacificAfrican American / BlackCaucasian / WhiteHispanic / LatinoNative AmericanBiracialOther
Full Time In Household (8)

YesNo
(9)

10
Name(9)

Last NameFirst Name
Gender(9)
Age in Years(9)
Relationship(9)
Monthly Income(9)
Ethnicity(optional)(9)

Asian PacificAfrican American / BlackCaucasian / WhiteHispanic / LatinoNative AmericanBiracialOther
Full Time In Household (9)

YesNo
(10)

10
Name(10)

:Last NameFirst Name
Gender(10)
Age in Years(10)
Relationship(10)
Monthly Income(10)
Ethnicity(optional)(10)

Asian PacificAfrican American/BlackCaucasian / WhiteHispanic / LatinoNative AmericanBiracialOther
Full Time In Household (10)

YesNo
(11)

10
Name(11)

Last NameFirst Name
Gender(11)
Age in Years(11)
Relationship(11)
Monthly Income(11)
Ethnicity(optional)(11)

Asian PacificAfrican American / BlackCaucasian / WhiteHispanic / LatinoNative AmericanBiracialOther
Full Time In Household (11)

YesNo
(12)

10
Name(12)

Last NameFirst Name
Gender(12)
Age in Years(12)
Relationship(12)
Monthly Income(12)
Ethnicity(optional)(12)

Asian PacificAfrican American / BlackCaucasian / WhiteHispanic / LatinoNative AmericanBiracialOther
Full Time In Household (12)

YesNo
(13)

10
Name(13)

Last NameFirst Name
Gender(13)
Age in Years(13)
Relationship(13)
Monthly Income(13)
Ethnicity(optional)(13)

Asian PacificAfrican Black / BlackCaucasian / WhiteHispanic / LatinoNative AmericanBiracialOther
Full Time In Household (13)

YesNo
(14)

10
Name(14)

Last NameFirst Name
Gender(14)
Age in Years(14)
Relationship(14)
Monthly Income(14)
Ethnicity(optional)(14)

Asian PacificAfrican American / BlackCaucasian / WhiteHispanic / LatinoNative AmericanBiracialOther
Full Time In Household (14)

YesNo
Shop Dates are Friday, December 6 through Saturday, December 14. Mark the times with an x you can come to shop.

Shop Times

	Fri 12/6	Sat 12/7	Sun 12/8	Mon 12/9	Tues 12/10	Wed 12/11	Thur 12/12	Fri 12/13	Sat12/14
9:00 - 12:00
12:00 - 3:00
3:00 - 5:30
5:30 - 7:30

Comments
Select yes below to declare the information to be true, authorize release of information to determine eligibility, and understand that you can only receive Holiday Assistance from one agency. Submitting an application does not guarantee an appointment.
Agree to statement above*

YesNo
Check In
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