Barrow County Holiday Connection
2017 Application for Assistance
Guardian/Caretaker Name *
Your answer
*
Relationship to Child *
Your answer
Phone Number *
Your answer
Email Address
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
What city do you live in? *
Do you qualify for free or reduced lunch? *
If no, please explain any special circumstance that requires you to seek Holiday Connection Assistance. Also, please provide the verifying agency.
Your answer
Were you referred to Holiday Connection through the United Way? *
Have you ever used Holiday Connection before? *
If so, how many years have you used Holiday Connection?
Years
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