Holiday Campaign Application – East Haddam Youth & Family Services, Inc.

Applications must be received no later than Friday, November 15th.

To apply for this program, you must complete the following information and provide proof of residency in the form of a household bill addressed to you and dated within the last 30 days (for example utility bill or rent/mortgage statement).

If your child is enrolled in the East Haddam School District, we will need you to sign the release giving us permission to confirm their enrollment. If your child is home-schooled, we will need a letter from you stating this and confirming that they live with you in East Haddam/Moodus. Also, your family income must fall within established income eligibility guidelines.

Parents/guardians will be notified by phone when their packages are complete. All gifts must be picked up by Friday, December 20th. Gifts remaining at EHYFS after the 20th will not be available for the holidays.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Cell Phone *

Email *

Relationship to Child/Children *

Parent
Legal Guardian
Other

If other, please specify

Please indicate if you are currently enrolled in any of the programs listed below (Check at least one and include case number, if applicable).

East Haddam Food Bank
Energy Assistance through Connecticut Renewal Team: Case Number________________
SNAP: Case Number:________________
WIC: Case Number:__________________

Children

Please provide as much information as possible and limit gift requests to ten (10) items.

Child #1:

Age:

Gender:

Shirt Size:

Pant Size:

Shoe Size:

Gift Ideas (Please be specific, no more than ten items):

Child #2:

Age:

Gender:

Shirt Size:

Pants Size:

Shoe Size:

Gift Ideas (Please be specific, no more than ten items):

Child #3:

Age:

Gender:

Shirt Size:

Pants Size:

Shoe Size:

Gift Ideas (Please be specific, no more than ten items):

Child #4:

Age:

Gender:

Shirt Size:

Pants Size:

Shoe Size:

Gift Ideas (Please be specific, no more than ten items):

Child #5:

Age:

Gender:

Shirt Size:

Pants Size:

Shoe Size:

Gift Ideas (Please be specific, no more than ten items):

Proof of Residency

Please upload a proof of residency dated within 30 days (Example: utility bill or Rent/Mortgage Statement).

Click or drag a file to this area to upload.

Please note, a proof of residency is required to participate in the holiday campaign. If you are unable to upload a copy of your proof of residence, please contact East Haddam Youth & Family Services at 860.873.3296.

Release of Information

I give my permission to the East Haddam School system to confirm my child/children's enrollment with East Haddam Youth & Family Services. I understand that this is part of my application for participation in the EHYFS Holiday Campaign.

I have read the above release and consent to have my child's enrollment confirmed by the East Haddam School system. *

Yes

Signature