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