2019 DECEMBER HOLIDAY PROGRAM APPLICATION
IMPORTANT! PLEASE READ
-ONLINE REGISTRATION: ENDS FRIDAY, NOVEMBER 22ND
-YOU MUST BE AN EXISTING CLIENT WHO HAS RECEIVED SERVICES IN 2019

FOOD BASKET
-LIMIT 1 BASKET PER HOUSEHOLD
-DISTRIBUTION: Local churches will distribute baskets between December 13th - 15th. You will be contacted directly by the churches 1-2 weeks before the distribution date.

GIFTS
-AGE REQUIREMENT: Children must be 18 years old or younger by 12/31/19 to participate.
-TO SCHEDULE PICK UP TIME: After your application has been approved, you will receive an email containing a link to schedule your gift pick up time. Approval process may take up to 10 days.
-DISTRIBUTION: Pick up date will be December 17th at the First Congregational Church, 1315 N. Pine Street, Rochester, MI 48307.

ONLINE REGISTRATION ENDS NOVEMBER 22ND.

QUESTIONS: CALL ROCHESTER AREA NEIGHBORHOOD HOUSE AT 248-651-5836, EXT 36.
Email address *
CLIENT ID (Your client number is available on the mailing label of the envelope) *
Your answer
YOUR LAST NAME *
Your answer
YOUR FIRST NAME *
Your answer
ADDRESS (include Apt./Lot/Unit # if applicable) *
Your answer
CITY *
Your answer
ZIP CODE *
Your answer
PRIMARY PHONE # (xxx-xxx-xxxx) *
Your answer
ALTERNATE PHONE # (xxx-xxx-xxxx)
If this phone belongs to someone else, please let them know you have provided this number to Neighborhood House as your alternate number.
Your answer
FAMILY STATUS (Select One) *
SPOUSE OR PARTNER NAME
Your answer
NUMBER OF PEOPLE IN HOUSEHOLD *
DISCLOSURE
IN ORDER TO PARTICIPATE OUR DECEMBER HOLIDAY PROGRAM, YOU MUST AGREE TO THE FOLLOWING:

1. I give Rochester Area Neighborhood House permission to provide basic identifying information to collaborating holiday support organizations, churches, and municipalities.

2. I agree to participate only with Rochester Area Neighborhood House for a Holiday Program this year. I understand that I will lose the opportunity to participate in this year's Holiday Program and potential loss of future service at Rochester Area Neighborhood House if I violate this agreement.

3. RANH has permission to leave a message at the phone numbers listed above.
DO YOU AGREE TO THESE TERMS? *
SELECT TODAY'S DATE *
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WILL YOU ALLOW US TO SHARE PHOTOS ON SOCIAL MEDIA?
WHAT ARE YOU APPLYING FOR? *
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