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Document 1174777

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Document 1174777
 Application for Holiday Assistance (Please print clearly. Your information will be shared with local agencies.) Todays date: __________________
Head of household name: _______________________________Phone: ___________________
Head of household address: ____________________________________________________
Head of household e-mail: _______________________________________________________
First/Last name of all/other adults in the household/home: ______________________________
_____________________________________________________________________________
Provide the following information for all children in your household. Please review the list on the back of this
page and write 3 suggestions for each child. We are not able to provide clothing.
***Use only the list provided or make a reasonable/practical gift suggestion***
Name
age/sex
school they attend
Relationship to
head of household
3 suggestions from list on the back
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
Return to your child’s school counselor no later than Friday 11/20/15. Applications may also be turned in at the
Pickerington Food Pantry on 11/16/15 6:30-8:30 PM or 11/21/15 10:00 AM- 12:00PM.
Late forms cannot be accepted.
Additional helpful resources • Fairfield County 211-­‐ general assistance (740) 687-­‐0500 • Maywood Mission-­‐ food, toys, clothes (740) 653-­‐4458 • Charity Newsies-­‐ food (740) 687-­‐0500 • Hands on Central Ohio (Franklin Co. 211) (614) 221-­‐6766 • Food Pantry (614) 834-­‐0079
*Office use only submitted form________
Action Figures
Activity Books
Art Supplies
Bath and Body items
Barbie Dolls
Bikes
Blocks/Building sets
Board Games
Books
Crafts
Disney Items
Fashion accessories (Teenage)
Headphones/Ear buds
Hand held game devices
Jewelry
Legos
Make-up and hair accessories
Perfume/Cologne
Puzzles
Science
Sports equipment
Stuffed animals
Toy trucks
Video games (indicate game system)
*Office use only submitted form________
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