Charitable Assistance Application

The Agreement for Services form must also be completed to be considered for Charitable Assistance.

Recipient’s Name

Recipient Birth Date

Contact Phone Number

E-mail Address

Race and Ethnicity of child:
White or Caucasian
Hispanic or Latino
Black or African American
Asian or Pacific Islander
Native American or Alaska Native
Other:
I prefer not to answer

Is the child adopted?:
Yes   No

Is the child in foster care?:
Yes  No

Annual household income:

Check one:
Single Income Household
Dual Income Household

Parent/Guardian(s) names:

Parent Guardian 1

Name:

Are you currently employed?
Yes   No

Employer:

Position:

Age:

Highest level of Education Completed:

Parent Guardian 2

Name:

Are you currently employed?
Yes No

Employer:

Position:

Age:

Highest level of Education Completed:

Household Info:

Please list names and birthdates of all dependents in the household.

Total number of family members living in household:

Are dependents enrolled in free/reduced school lunch program?
Yes No

Please describe any recent family events that warrant special consideration (i.e. illness, death, divorce, natural disasters, etc).

Personal appeals describing the need for charitable assistance are encouraged.

I promise that the information I submit on this Application is true, to the best of my knowledge.
Signature of Applicant

Reset Signature

One of the following documents must be included for income verification:

W-2 or W-9
Pay stub for all parents/guardian(s) living with child

Applications submitted with no proof of income will NOT be reviewed.

Submit