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Santa's Helpers
Application for services
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Email
*
Your email
Are you referring a family or a self referral? (If self referring, provide a verification reference under referral's info)
Family
Self
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Referral's contact information (name and phone# of reference from outside the home.)
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Family Name (Last, First)
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Phone Number
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Address
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Did the family receive assistance from Santa's Helpers last year?
Yes
No
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Is the family receiving assistance from another non-profit organization?
Love Inc
Salvation Army
None
Other:
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Mother
Your answer
Father
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Any other adults in the household
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# of Children
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Child 1 Name
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Child 1 Age
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Child 1 Gender
Male
Female
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Child 1 Relationship to Family
Your answer
Child 2 Name
Your answer
Child 2 Age
Your answer
Child 2 Gender
Male
Female
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Child 2 Relationship to Family
Your answer
Child 3 Name
Your answer
Child 3 Age
Your answer
Child 3 Gender
Male
Female
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Child 3 Relationship to Family
Your answer
Child 4 Name
Your answer
Child 4 Age
Your answer
Child 4 Gender
Male
Female
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Child 4 Relationship to Family
Your answer
Child 5 Name
Your answer
Child 5 Age
Your answer
Child 5 Gender
Male
Female
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Child 5 Relationship to Family
Your answer
Any Additional Children
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Do any of the children have special needs? Please explain.
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Do all your children have bicycles? If not, who does not?
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