Santa for Seniors 2024

Santa for Seniors
Santa for Seniors 2025 Application Form
Forms must be submitted no later than Thursday, December 11.
**Please note - if we do not have all information, we may be unable to deliver to the intended recipient!
I will pick up my package.

YesNo
Dentures?

YesNo
Adult Diapers?

YesNo
Diabetic?

YesNo
Male or Female?

MaleFemale
Applicant Name

First NameLast Name
Applicant Address
Your Street Address (MUST BE INCLUDED FOR INCLUSION!):
Age
Phone number
Clothing size, Shoe Size, Special needs.
Directions to applicant home. (THIS IS VERY IMPORTANT)
Should be Empty: