Parent/Guardian's Legal Name *

First Name

Last Name

Relation *

If you do not match one of the following descriptions, please email us at NorthPole@Christmas4Kidz.org. Please keep in mind you may need to provide additional documentation for verification.

I am the parent of the children I list

I am the legal guardian of the children I list

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Completing this form does not guarantee acceptance into the Christmas4Kidz program. We will try to help as many families as we are financially able to. *

I understand my family may not be chosen

Upon completion of this form, until told I have not been accepted into this program, I will NOT place my name or my child(ren)'s name(s) on another other holiday assistance list with the exception of food pantries. *

I will not sign up for other holiday assistance

I understand that if I fail to notify other agencies and do accept assistance elsewhere in addition to this program that my family and I will permanently forfeit our eligibility for this program for this year and all future years. *

In addition, I understand that partners may choose to permanently terminate my family’s eligibility for services they offer also.

I will notify other agencies if accepted into this program

I authorize any representative from this program to check with other agencies in the area that are providing Christmas assistance to ensure that we are not also registered with them. This includes, but is not limited to: *

Community Action (CAWM), Spencer Village/Pantry, Matthew 25, Any Salvation Army, People to People, Any Good Samaritans, Love Inc., Any Toys for Tots, Cloverleaf School District, Any Church, and Oaks Family Care Center

I Agree

I give permission for my family's wish-list to be shared with potential sponsors. This list is provided without names but will include child(rens) age(s). *

I Agree

I understand that it is my responsibility to ensure that gifts are age appropriate, in working order and played with properly. I release from liability any and all Christmas4Kidz program providers in the partnership and am grateful for the assistance. *

I Agree

First Child's Gender *

Male

Female

Gender Neutral

First Child's Ears Pierced *

Yes

No

Second Child's Gender

Male

Female

Gender Neutral

Second Child's Ears Pierced

Yes

No

Third Child's Gender

Male

Female

Gender Neutral

Third Child's Ears Pierced

Yes

No

Fourth Child's Gender

Male

Female

Gender Neutral

Fourth Child's Ears Pierced

Yes

No

Fifth Child's Gender

Male

Female

Gender Neutral

Fifth Child's Ears Pierced

Yes

No

Sixth Child's Gender

Male

Female

Gender Neutral

Sixth Child's Ears Pierced

Yes

No