Christmas Assistance Application Form

TheHouse of Dreams Christmas Assistance Application, 2024

Fill out the form carefully for registration
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
2nd Name:

First NameLast Name
Date of Birth *required

MonthDayYear
Date
Relationship to you
Type spouse, partner, parent, child, or other
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 of rent paid by Section 8 Monthly:
Type Amount
Amount of SSI/SSD 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 explanation or put n/a
Total Household Monthly Expenses:
Fill in all blanks. If not applicable, enter '0'
Rent/Mortgage:
Type Amount
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? 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, and Birth Certificates required for proof of Guardianship *

Cancelof
Are you going to request assistance from anywhere else?*
Do you attend church regularly? (this has no effect on your application)*
If your answer was yes, which church do you attend? Church Name
Would you like a visit from our church after the Holidays? (this has no effect on your application) YesNo

*all request may not be accepted, due to donations and availability.
Should be Empty:

TheHouse of Dreams Christmas Assistance Application, 2024

Children in Home (12 and under)

Monthly Income:

Total Household Monthly Expenses: