Help for the Holidays Application

Help for the Holidays Application

Brier Helping Brier
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of children you plan to have for the holidays? *
I need assistance for the holidays with (select all that apply):

FoodGifts
I would prefer a gift card from:

Fred MeyerWalmartAmazon
I live inside the service area for Brier Helping Brier*

YesNoNot Sure
*Gift cards provided should be used for appropriate holiday expenses, such as food and gifts for your family. If your household needs additional financial assistance, please consider applying for aid.
Should be Empty: