Application Page

The Elf Project for A Child’s Christmas
PO Box 151
Lenoir City, TN 37771
Please print this page and send to the address above. Deadline is November 14, 2017. Please print clearly.

Name: ___________________________________________

Address: _________________________________________________________________

Dependable phone numbers where we can reach you:

_________________________________________

Married ____ Separated ____ Divorced ____ Single ____

Social Security #: _________________________

Occupation(s): __________________________

Monthly Household Income: $____________

Do you have other income (child support, SSI, WIC, etc)?
Yes ____ No ____

If yes, source: ______________________________

Amount per month: ________

Please give the names and ages of your children 12 and under:

_______________________________________

_______________________________________

_______________________________________

_______________________________________
(use the back if needed)

On reverse please add any circumstance that will help us assess your need. All information will remain confidential.

Applicant signature__________________________________________

This section to be completed by agency representative who will verify your need (Family Promise, Head Start, Church pastor, Community Chest, Helen Ross McNabb, etc.)

Name: ______________________________________

Organization: _________________________________

Phone Number: ___________________Ext____________

Comments: _____________________________________ _________________________________

Remember Deadline is November 14, 2017.