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FAMILY SERVICE AGENCY 2026 CHRISTMAS APPLICATION
ALL PAGES MUST BE COMPLETED IN FULL TO RECEIVE ASSISTANCE
Important Note:
If you apply/have applied with any other agency, church, or group for help with Christmas for your child/children your application will be voided and the other agency will be informed - we cannot duplicate services for a child that is already signed up elsewhere, it takes Christmas away from other child in need.)
NUMBER OF PEOPLE THAT ARE CURRENTLY LIVING AT THIS ADDRESS
*
EVERYONE CURRENTLY LIVING IN THE HOUSEHOLD. We will need a picture ID and Social for everyone 18+ in the home.
HOW MANY CHILDREN UNDER 18 LIVE AT THIS ADDRESS
*
CHILDREN RECEIVING CHRISTMAS MUST PERMANENTLY RESIDE AT THE ADDRESS OF THE PERSON FILLING OUT THIS APPLICATON. We will need at birth certificate for each child
FAMILY DESCRIPTION
*
Single-Parent Family (only one adult parental figure living in the Household)
Two-Parent Family (only two adult parental figures living in the household)
Multiple-Family Household (each family in household will need to do a separate application)
Other
Are you homeless?
*
NO (I RENT my apartment/home)
NO (I OWN my apartment/home)
YES (I am homeless but am couch-surfing, staying temporarily with friends and/or family)
YES (I am homeless and living in a tent or in my car)Type option 6
Other
Are you a Veteran (with a DD-214)?
*
Yes
No
REFERRED BY - HOW DID YOU HEAR ABOUT US?
*
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ABOUT YOU (the primary person filling out this application)
(The primary custodial parent of the children receiving Christmas - YOU WILL BE SHOPPING FOR YOUR CHILD/CHILDREN)
FULL LEGAL NAME OF PRIMARY PARENT or LEGAL GUARDIAN: (on your ID)
*
First Name
Middle Name
Last Name
Suffix
PHONE NUMBER: (CELL PREFERRED)
*
Please enter a valid phone number. This is for us to contact you about your appointment time and/or questions about gifts. If your phone is unavailable, restricted, if the voicemail is full or if voicemail is not set up then we will call your emergency contact. It is your responsibility to let us know if your phone number changes between the time you apply and Christmas.
Format: (000) 000-0000.
EMAIL:
*
example@example.com
DATE OF BIRTH:
*
/
Month
/
Day
Year
Date Picker Icon
GENDER:
FEMALE
MALE
Other
RACE AND ETHNICITY:
*
Please Select
AMERICAN INDIAN or ALASKAN NATIVE
ASIAN
BLACK or AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
TWO or MORE RACES (MIXED)
WHITE (HISPANIC)
WHITE (NON-HISPANIC)
OTHER
VETERAN STATUS:
Yes, I am a Veteran
No, I am NOT a Veteran
IN THE LAST 30 days, HAVE YOU BEEN A VICTIM OF DOMESTIC VIOLENCE?
*
Please Select
YES
NO
IN THE LAST 30 days, HAVE YOU EXPERIENCED A HOUSEFIRE OR NATURAL DISASTER?
*
Please Select
YES
NO
PHYSICAL ADDRESS (where you live/sleep regularly):
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you lived at the above address?
*
Please Select
Less than 7 months
More than 7 months but less than 1 year
1-3 years
More than 3 years
MAILING ADDRESS (If you are homeless, where do you receive mail):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
MARITAL STATUS:
SINGLE
MARRIED
SEPARATED
DIVORCED
WIDOWED
Other
What method(s) of Transportation do you use (CHOOSE ALL THAT APPLY):
*
I have a car or truck
I have a bicycle
I ride the trolley/bus
I walk (I have no other form of transportation)
A friend or relative has to drive me where I need to go
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OTHERS LIVING IN YOUR HOME
(DO NOT INCLUDE YOURSELF - YOU ARE UP TOP)
ARE THERE ANY VETERANS LIVING IN YOUR HOUSHOLD (not including you)?
*
Please Select
YES
NO
If YES, What is the Veterans name and relation to you?
*
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IF THIS IS A TWO-PARENT HOUSEHOLD (or you would like to designate another adult to shop for your children in the event you have to work or cannot come shop yourself), please add their name and information here.
(This person would need to bring ID with them that matches the name you complete here)
FULL LEGAL NAME: (on ID) -this person will only be able to shop for the children on this application-
*
First Name
Middle Name
Last Name
Suffix
DESIGNATED SHOPPER PHONE NUMBER: (CELL PREFERRED)
*
Please enter a valid phone number.
Format: (000) 000-0000.
DESIGNATED SHOPPER Relationship to the Applicant
*
Please Select
SPOUSE or PARTNER
MOTHER
FATHER
SISTER
BROTHER
ADULT SON
ADULT DAUGHTER
COUSIN
FRIEND
OTHER
ID WILL BE REQURED TO SHOP FOR YOUR CHILDREN
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CHILDREN UNDER 18 THAT WILL BE RECEIVING CHRISTMAS
All children must live in the household of the PRIMARY APPLICANT and that person must have legal custody of the children.
CHILD #1 (Please list oldest to youngest)
*
First Name
Middle Name
Last Name
Suffix
CHILD #1 Relationship to the applicant
*
Son
Daughter
Grandson (you have legal custody)
Granddaughter (you have legal custody)
Nephew (you have legal custody)
Niece (you have legal custody)
Cousin (you have legal custody)
Foster Son
Foster Daughter
Step Son (they live with your more than 50% of the time)
Step Daughter (they live with you more than 50% of the time)
Other
CHILD #1 Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
CHILD #1 Sex:
MALE
FEMALE
CHILD #1 Race & Ethnicity
*
Please Select
AMERICAN INDIAN or ALASKAN NATIVE
ASIAN
BLACK or AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
TWO or MORE RACES (MIXED)
WHITE (HISPANIC)
WHITE (NON-HISPANIC)
OTHER
WHAT WOULD YOUR CHILD LIKE FOR CHRISTMAS?
We are are not able to provide: Clothes, Furniture, Large Dollhouses or other Large Items, Gaming Systems, TVs, Electric Scooters, Electric Bikes, Computers, Laptops, or other expensive items over $50)
Child #1 Wish List Item 1:
Child #1 Wish List Item 2:
Child #1 Wish List Item 3:
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CHILD #2: (Please list oldest to youngest)
*
First Name
Middle Name
Last Name
Suffix
CHILD #2 Relationship to the applicant
*
Son
Daughter
Grandson (you have legal custody)
Granddaughter (you have legal custody)
Nephew (you have legal custody)
Niece (you have legal custody)
Cousin (you have legal custody)
Foster Son
Foster Daughter
Step Son (they live with your more than 50% of the time)
Step Daughter (they live with you more than 50% of the time)
Other
PERSON #2 Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
CHILD #2 Sex:
MALE
FEMALE
PERSON #2 Race & Ethnicity:
*
Please Select
AMERICAN INDIAN or ALASKAN NATIVE
ASIAN
BLACK or AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
TWO or MORE RACES (MIXED)
WHITE (HISPANIC)
WHITE (NON-HISPANIC)
OTHER
WHAT WOULD YOUR CHILD LIKE FOR CHRISTMAS?
We are are not able to provide: Clothes, Furniture, Large Dollhouses or other Large Items, Gaming Systems, TVs, Electric Scooters, Electric Bikes, Computers, Laptops, or other expensive items over $50)
Child #2 Wish List Item 1:
Child #2 Wish List Item 2:
Child #2 Wish List Item 3:
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CHILD #3: (Please list oldest to youngest)
*
First Name
Middle Name
Last Name
Suffix
CHILD #3 Relationship to the applicant
*
Son
Daughter
Grandson (you have legal custody)
Granddaughter (you have legal custody)
Nephew (you have legal custody)
Niece (you have legal custody)
Cousin (you have legal custody)
Foster Son
Foster Daughter
Step Son (they live with your more than 50% of the time)
Step Daughter (they live with you more than 50% of the time)
Other
CHILD #3 Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
CHILD #3 Sex:
*
MALE
FEMALE
CHILD #3 Race & Ethnicity:
*
Please Select
AMERICAN INDIAN or ALASKAN NATIVE
ASIAN
BLACK or AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
TWO or MORE RACES (MIXED)
WHITE (HISPANIC)
WHITE (NON-HISPANIC)
OTHER
WHAT WOULD YOUR CHILD LIKE FOR CHRISTMAS?
We are are not able to provide: Clothes, Furniture, Large Dollhouses or other Large Items, Gaming Systems, TVs, Electric Scooters, Electric Bikes, Computers, Laptops, or other expensive items over $50)
Child #3 Wish List Item 1:
Child #3 Wish List Item 2:
Child #3 Wish List Item 3:
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CHILD #4: (Please list oldest to youngest)
*
First Name
Middle Name
Last Name
Suffix
CHILD #4 Relationship to the applicant
*
Son
Daughter
Grandson (you have legal custody)
Granddaughter (you have legal custody)
Nephew (you have legal custody)
Niece (you have legal custody)
Cousin (you have legal custody)
Foster Son
Foster Daughter
Step Son (they live with your more than 50% of the time)
Step Daughter (they live with you more than 50% of the time)
Other
PERSON #4 Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
CHILD #4 Sex:
*
MALE
FEMALE
CHILD #4 Race & Ethnicity:
*
Please Select
AMERICAN INDIAN or ALASKAN NATIVE
ASIAN
BLACK or AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
TWO or MORE RACES (MIXED)
WHITE (HISPANIC)
WHITE (NON-HISPANIC)
OTHER
WHAT WOULD YOUR CHILD LIKE FOR CHRISTMAS?
We are are not able to provide: Clothes, Furniture, Large Dollhouses or other Large Items, Gaming Systems, TVs, Electric Scooters, Electric Bikes, Computers, Laptops, or other expensive items over $50)
Child #4 Wish List Item 1:
Child #4 Wish List Item 2:
Child #4 Wish List Item 3:
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CHILD #5: (Please list oldest to youngest)
*
First Name
Middle Name
Last Name
Suffix
CHILD #5 Relationship to the applicant
*
Son
Daughter
Grandson (you have legal custody)
Granddaughter (you have legal custody)
Nephew (you have legal custody)
Niece (you have legal custody)
Cousin (you have legal custody)
Foster Son
Foster Daughter
Step Son (they live with your more than 50% of the time)
Step Daughter (they live with you more than 50% of the time)
Other
CHILD #5 Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
CHILD #5 Sex:
*
MALE
FEMALE
CHILD #5 Race & Ethnicity:
*
Please Select
AMERICAN INDIAN or ALASKAN NATIVE
ASIAN
BLACK or AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
TWO or MORE RACES (MIXED)
WHITE (HISPANIC)
WHITE (NON-HISPANIC)
OTHER
WHAT WOULD YOUR CHILD LIKE FOR CHRISTMAS?
We are are not able to provide: Clothes, Furniture, Large Dollhouses or other Large Items, Gaming Systems, TVs, Electric Scooters, Electric Bikes, Computers, Laptops, or other expensive items over $50)
Child #5 Wish List Item 1:
Child #5 Wish List Item 2:
Child #5 Wish List Item 3:
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CHILD #6: (Please list oldest to youngest)
*
First Name
Middle Name
Last Name
Suffix
CHILD #6 Relationship to the applicant
*
Son
Daughter
Grandson (you have legal custody)
Granddaughter (you have legal custody)
Nephew (you have legal custody)
Niece (you have legal custody)
Cousin (you have legal custody)
Foster Son
Foster Daughter
Step Son (they live with your more than 50% of the time)
Step Daughter (they live with you more than 50% of the time)
Other
CHILD #6 Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
CHILD #6 Sex:
*
MALE
FEMALE
CHILD #6 Race & Ethnicity:
*
Please Select
AMERICAN INDIAN or ALASKAN NATIVE
ASIAN
BLACK or AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
TWO or MORE RACES (MIXED)
WHITE (HISPANIC)
WHITE (NON-HISPANIC)
OTHER
WHAT WOULD YOUR CHILD LIKE FOR CHRISTMAS?
We are are not able to provide: Clothes, Furniture, Large Dollhouses or other Large Items, Gaming Systems, TVs, Electric Scooters, Electric Bikes, Computers, Laptops, or other expensive items over $50)
Child #6 Wish List Item 1:
Child #6 Wish List Item 2:
Child #6 Wish List Item 3:
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CHILD #7: (Please list oldest to youngest)
*
First Name
Middle Name
Last Name
Suffix
CHILD #7 Relationship to the applicant
*
Son
Daughter
Grandson (you have legal custody)
Granddaughter (you have legal custody)
Nephew (you have legal custody)
Niece (you have legal custody)
Cousin (you have legal custody)
Foster Son
Foster Daughter
Step Son (they live with your more than 50% of the time)
Step Daughter (they live with you more than 50% of the time)
Other
CHILD #7 Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
CHILD #7 Sex:
*
MALE
FEMALE
CHILD #7 Race & Ethnicity:
*
Please Select
AMERICAN INDIAN or ALASKAN NATIVE
ASIAN
BLACK or AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
TWO or MORE RACES (MIXED)
WHITE (HISPANIC)
WHITE (NON-HISPANIC)
OTHER
WHAT WOULD YOUR CHILD LIKE FOR CHRISTMAS?
We are are not able to provide: Clothes, Furniture, Large Dollhouses or other Large Items, Gaming Systems, TVs, Electric Scooters, Electric Bikes, Computers, Laptops, or other expensive items over $50)
Child #7 Wish List Item 1:
Child #7 Wish List Item 2:
Child #7 Wish List Item 3:
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CHILD #8: (Please list oldest to youngest)
*
First Name
Middle Name
Last Name
Suffix
CHILD #8 Relationship to the applicant
*
Son
Daughter
Grandson (you have legal custody)
Granddaughter (you have legal custody)
Nephew (you have legal custody)
Niece (you have legal custody)
Cousin (you have legal custody)
Foster Son
Foster Daughter
Step Son (they live with your more than 50% of the time)
Step Daughter (they live with you more than 50% of the time)
Other
CHILD #8 Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
CHILD #8 Sex:
*
MALE
FEMALE
CHILD #8 Race & Ethnicity:
*
Please Select
AMERICAN INDIAN or ALASKAN NATIVE
ASIAN
BLACK or AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
TWO or MORE RACES (MIXED)
WHITE (HISPANIC)
WHITE (NON-HISPANIC)
OTHER
WHAT WOULD YOUR CHILD LIKE FOR CHRISTMAS?
We are are not able to provide: Clothes, Furniture, Large Dollhouses or other Large Items, Gaming Systems, TVs, Electric Scooters, Electric Bikes, Computers, Laptops, or other expensive items over $50)
Child #8 Wish List Item 1:
Child #8 Wish List Item 2:
Child #8 Wish List Item 3:
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EMERGENCY CONTACT INFORMATION
CLOSEST FRIEND OR RELATIVE THAT DOES NOT LIVE WITH YOU? (Preferably that lives in Bay County or a surrounding county)
*
First Name
Middle Name
Last Name
Suffix
PHONE NUMBER of CLOSEST FRIEND OR RELATIVE THAT YOU LISTED ABOVE
*
Please enter a valid phone number. This is for us to contact you about your appointment time if your primary phone number doesn't work, is restricted, or if the voicemail is full or not set up.
Format: (000) 000-0000.
Is this a friend or relative (if relative, what is the relationship)?
*
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CIRCUMSTANCES: Why are you needing assistance (Disability, Accident, Injury, Illness, Hospitalization, Pregnancy, Car Repairs, or just struggling financially, explain the best you are able)
*
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FINALLY... READ THAT FOLLOWING, CHECK AND SIGN ELECTRONICALLY.
I agree that I accept all Christmas gifts free of charge, with no warranty made or implied by FSA, that they are as is, and that I will not sell or return them for profit. Any proof received that they have been sold for profit will result in you no longer being able to get Christmas in the future.
YES, I UNDERSTAND
THIS APPLICATION IS ONLY FOR ASSISTANCE WITH CHRISTMAS, FOR ALL OTHER SERVICES PLEASE RETURN TO OUR WEBSITE AND FILL OUT OUR REGULAR AGENCY APPLICATION.
(OTHER SERVICES INCLUDE FREE CLOTHING, BABY DIAPERS, MEDICAL EQUIP & SUPPLIES, WORK SHOES/BOOTS, HYGIENE/CLEANING SUPPLIES, HOMELESS SERVICES, ETC)
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