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READ and SIGN CONSENT before completing this application I HAVE NOT and WILL NOT ask for Christmas help from ANY other organization. I certify that all the information I provided in this application is accurate, and I understand that it may be verified with other organizations assisting families at Christmas. I also give consent to the L.H.F.O.H to make inquiries of Social Services or other agencies to verify my information. I agree to assume full responsibility for all aspects of my participation in the L.H.F.O.H and release L.H.F.O.H from any damages which I may sustain thereby.

Date *

E Signature


Parent/Guardian Name:



Total Monthly Income:

Total Monthly Income:

Food Stamps (amount)

TANF (amount)

Case Worker

Social_Security (amount)

Child Support (amount)

Unemployment (amount)

If a doll is requested, what nationality do you prefer

Select an option

Any special request needed:

Child # / Name / Sex / Age / Shoe Size / Shirt Size / Pant Size / Wish List / Relation to Applicant

PLEASE READ: 1. COMPLETION OFTHIS APPLICATION DOES NOT AUTOMATICALLY GUARANTEE THAT YOUR FAMILY WILL BE SELECTED. 2. This assistance program is designed to supplement your Christmas needs and not be a complete substitution. 3. To ensure that as many families as possible get an opportunity to take advantage of the program, we must take into consideration the number of times your family has received assistance in past years. However, this will not automatically disqualify your family from receiving assistance again. 4. Applications are NOT selected on a first come, first served basis. 5. We work closely with other organizations in/outside the county to cross-check family’s names to ensure there are no duplications of services.


E Signature

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