The Elf Project for A Child's Christmas
    PO Box 151
    Lenoir City, TN 37771

    Please print this page, give to your reference person, and send to the address above.
    Reference must be professional who can verify your situation. Deadline is November 15.
    Please print clearly.

    Name: ___________________________________________

    Address: _________________________________________

      _________________________________________

    Dependable phone numbers where we can reach you:      __________________   _______________________

    Married____  Separated____  Divorced ____  Single____

    Social Security #: ________________________________

    Current employment: ______________________________

    Monthly Household Income: $____________

    Check if you or your children receive:

    _____Food Stamps (SNAP)    _____WIC     _____TennCare/Kids               _____Disability SSI     _____Child Support:
      
    Total 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.

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

    Name: _________________________________________

    Organization: _________________________________

    Phone Number: ___________________Ext____________

    Comments: ____________________________________________________________________________________

    Remember Deadline is November 15