"Share the Joy" Christmas Assistance Program 2024

"Share the Joy" Seniors (used by Amen House ONLY)

Senior Information
Senior Name*

First NameMiddle NameLast Name
Address*

Street

Street Address Line 2

CityState

Zip Code
Age*
Must be 62 or over!
Gender*

MaleFemale
Email*
example@example.com
Phone*
Enter phone as 10 digits with no spaces

Secondary Contact Information
Secondary Name*

First NameMiddle NameLast Name
Secondary Email*
example@example.com
Secondary Phone*
Enter phone as 10 digits with no spaces

Senior Preferences and Wishes
Color*
What is your favorite color?
Interests*
What are your interests?
Three Wishes - Please complete the 3 below lines with:

Something the Senior needs (clothing, shoes, hygiene products)
Something the Senior wants (toys, electronics, supplies)
Please: be specific with sizes, products, or style
Please: no electronics over $50
First Wish*
Second Wish*
Third Wish*
Comments
Add any optional comments that could be helpful

Certification
Identification*

Upload Photo Identification Card or Government ID (submit for each adult)
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Residency*

Upload Proof of Residency, utility bill, rental contract.
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Verification*

AMEN House associate: scan your photo ID or business card
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I certify that the information submitted in this application to be true and correct to the best of my knowledge. I further understand that any false information could result in being denied assistance from the program. I also give permission for my information to be shared with an approved sponsor of the Share The Joy program.
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