Holiday Help Family Application

Head of Household Information:

Your full name

Street Address
City

State
Zipcode

Your Home Phone
Your Work Phone

Your email
Your Date of Birth (mm/dd/yyyy)

Dependent Information

Please list the names, gender and age of each dependent (including adults) in this format: Name, Gender, Age, Wish list. One dependent per line.

Household Income

Gross Monthly Household Income
Monthly Bills

Personal Information

Please briefly describe any concerns that may help us to better understand your circumstance and why you and your family would be good candidates for sponsorship (e.g. health concerns, job loss, recent family death, housing issues). If you have any supporting documentation of this circumstance, please upload a file below (not required).

Note: To replace a file you uploaded, click the Choose File button again, select a new file and click Open, or click Cancel to remove the file. Maximum file size is 10MB.

Declaration of Need and Risk/Release Waiver

In consideration of being permitted to participate in the Good in the ‘Hood Holiday Help program, on behalf of myself, or a minor child or ward, heir, next of kin, personal representative, successor or assign;

I ACKNOWLEDGE, UNDERSTAND AND DECLARE THAT:
- To the best of my knowledge, I am in a state of economic and/or personal hardship and in need of the support being offered through the programs associated with Good in the ‘Hood.
- I commit to use the programs and gifts for the purpose intended and will not sell, barter, or trade the gifts and commodities received through my association with Good in the ‘Hood.
I ASSUME ALL OF THE ABOVE RISKS AND RELEASE, WAIVE, DISCHARGE, HOLD HARMLESS, INDEMNIFY AND COVENANT NOT TO SUE:
1. Good in the Hood and/or other affiliated partners, other volunteers, and sponsors FROM ANY AND ALL LIABILITY FOR INJURY, INCLUDING DEATH, EMOTIONAL TRAUMA, AND LOSS OR DAMAGE TO ME OR MY PROPERTY, OR ANY OTHER CONSEQUENCE in connection with my participation with “Good in the ‘Hood”.
My family and I CONSENT TO:
1. ALLOW our PHOTOGRAPH(s), PICTURE(s), LIKENESS(es), VIDEO and/or VOICE(s) to be used for Good in the Hood and our program partner materials and promotions.
2. Meet with our sponsors in order to receive any gifts/commodities being offered.
I TESTIFY THAT ALL INFORMATION IN THIS APPLICATION IS ACCURATE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

Please check here if you accept these terms

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