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
-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.
-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.
CLIENT ID (Your client number is available on the mailing label of the envelope)
YOUR LAST NAME
YOUR FIRST NAME
ADDRESS (include Apt./Lot/Unit # if applicable)
PRIMARY PHONE # (xxx-xxx-xxxx)
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.
FAMILY STATUS (Select One)
Single with children
Married with children
SPOUSE OR PARTNER NAME
NUMBER OF PEOPLE IN HOUSEHOLD
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
WILL YOU ALLOW US TO SHARE PHOTOS ON SOCIAL MEDIA?
WHAT ARE YOU APPLYING FOR?
Gifts for children 18 years old or younger by 12/31/19
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