2023 HOLIDAY PROGRAM APPLICATION

Must be submitted by November 17th
 

NAME_____________________________________________PHONE_____________________

SPOUSE/SIGNIFICANT OTHER___________________________________________________

EMAIL ________________________________________________________________________

STREET ADDRESS__________________________________TOWN_______________________
DESCIBE HOUSE AND LOCATION _______________________________________________

______________________________________________________________________________

 

HOUSEHOLD MAKE-UP: (provide number of children for each age range)

Age 1-12 ______   Age 13-18 ______   Age 19-61 ______   Age 62+ ______

(If you have a child/children under age 13, please fill out the second page of this application,                                one page for each child under the age of 13)

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EMPLOYED:  YES ____  NO ____  WHERE: ____________________________________________
SPOUSE/SIGNIFICANT OTHER:  YES____ NO ____ WHERE:_____________________________

WEEKLY PRE-TAX WAGES:  SELF: $_________SIGNIFICANT OTHER: $___________

 

OTHER INCOME:
PUBLIC ASSISTANCE:  $________ UNEMPLOYMENT: $ ________    SOCIAL SECURITY: $________                   WORKER'S CCOMPENSATION: $ ________________REACH-UP: $____________                                          CHILD SUPPORT: $ __________  FOOD STAMPS: $______________

OTHER INCOME: $ _____________

 

EXPENSES:
RENT: $ _________  ELECTRICITY: $ _________  HEAT: $____________

SIGNATURE _____________________________________ DATE ____________________

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(Black River Good Neighbor Services reserves the right to refuse any application.)             Page 1 of 2