SHOP with a COP
Event Date: December 9, 2023 (TIMES TO BE ASSIGNED)
Event Address: Target Oxford Valley 2331 Lincoln Highway Langhorne, PA 19047
Contact us at (215) 750-3876  or mtpdnno@gmail.com
Email *
APPLICATION DEADLINE: November 26, 2023
The Shop with a Cop program is designed to afford local families a better holiday. The 8th annual Shop with a Cop will take place on Saturday, December 9, 2023 beginning at 8:30 am at the OXFORD VALLEY Target. Eligible families must submit their FULLY completed application to be considered. All application records are kept strictly confidential. Incomplete applications WILL NOT be reviewed. It is the responsibility of the applicant to make sure the application is complete, including the wish list below. Saying that you will "bring a wish list" to the event, or only providing one or two gift ideas is NOT considered complete. Provide as many gift ideas as possible and include gifts for family members as well. 

An officer will contact you to advise you that you have been chosen to participate. Please note that we have hundreds of applications each year and we will do our best to accommodate as many children as possible. If you do not receive a response to your application, unfortunately your child(ren) were not chosen this year. 
ELIGIBILITY 
To be eligible you must reside in Bucks County. Eligible children attend a school in Bucks County to include all private, charter, online and special needs institutions.  *
To be eligible your child or children MUST be between the ages of 4 and 13 years old. Case by case exceptions may be made at our discretion. *
To be eligible, your family must be faced with a life challenge, such as: *
Please provide us detailed information about your hardship that would explain why your family would be a good candidate for Shop with a Cop. We use this information to determine eligibility and priority. We ask that you be as specific as possible to help guide this difficult decision making process. Any misrepresentation of yourself or your situation, will exclude you from participation in this event.  Thank you! *
Have you participated in Shop with a Cop before? Previous participation does not mean that you will automatically be approved or denied. Please answer the questions honestly, as we keep records of all previous years.  *
Have you applied for assistance from other holiday help programs? If yes, please name the organization below. If no, simply write "no" on the line below. *
CONTACT INFORMATION
Parent/Guardian FULL Name *
Address of Child/Children:
Street Address
City, State Zip
 *
Phone Number for Parent/Guardian *
Email for Parent/Guardian *
Place of Employment for Parent/Guardian *
Occupation of Parent/Guardian *
First and Last Name of Eligible Child #1 *
Age of Eligible Child #1 *
Gender of Eligible Child #1 *
Relationship of Eligible Child #1 to you *
What school does child #1 attend?  *
First and Last Name of Eligible Child #2 or N/A *
Age of Eligible Child #2 *
Gender of Eligible Child #2 *
Relationship of Eligible Child #2 to you *
What school does child #2 attend? or N/A *
First and Last Name of Eligible Child #3 or N/A *
Age of Eligible Child #3 *
Gender of Eligible Child #3 *
Relationship of Eligible Child #3 to you *
What school does child #3 attend? or N/A *
First and Last Name of Eligible Child #4 or N/A *
Age of Eligible Child #4 *
Gender of Eligible Child #4 *
Relationship of Eligible Child #4 to you *
What school does child #4 attend? or N/A *
First and Last Name of Eligible Child #5 or N/A *
Age of Eligible Child #5 *
Gender of Eligible Child #5 *
Relationship of Eligible Child #5 to you *
What school does child #5 attend? or N/A *
Is there anything special that we should know about your child or children to ensure they have the absolute best time? Do they have any kind of super powers (sometimes called disabilities) that we should know about? Do they use a wheelchair or walker? Are they extraordinarily shy? Tell us something, anything, we want to hear it!  *
Every child will be assigned a time slot to shop. Please choose up to 3 time slots that will work best for your family and schedule.  *
Required
By typing your name below you are certifying that the information on this application is true and complete to the best of your knowledge. If you misrepresent yourself or your hardship, your application will no longer be considered for this, or future Shop with a Cop events.  *
MIDDLETOWN TOWNSHIP POLICE DEPARTMENT IN PARTNERSHIP WITH SURROUNDING LAW ENFORCEMENT AGENCIES PARTICIPANT RELEASE, DISCHARGE, WAIVER AND COVENANT NOT TO SUE
Release from liability and covenant not to sue. Each Participant and his/her parent or guardian agrees, for itself and its personal representatives, executors, administrators, heirs, next of kin and assigns, to release and discharge the Program (Middletown Twp Police Department, Lower Southampton Police Department, Newtown Township, Newtown Borough, any other participating Police Departments, sponsors, and promoters of any and all programs or any part thereof and each of their respective parents, subsidiaries, partnerships, stockholders, owners, governors, partners and other affiliates, and each officer, director, governor, shareholder, employee, other official, representative and agent of each of the foregoing, and all of the foregoing’s respective successors and assigns), from, and waive in respect of each and covenant not to sue any for, any and all liabilities, losses, damages, costs, expenses (including but not limited to attorneys’ fees and expenses), causes of action, suits and claims of any nature whatsoever, arising from, based upon or relating to personal injury or death to, or damage to or loss of property of, the Participant or his/her parent or guardian sustained in connection with the Participant’s participation in the program or travel to or from the program’s center. Such release, discharge, waiver and covenant not to sue shall include, but not be limited to, any and all such liabilities cause in whole or in part by the negligence of any in connection with such involvement with the program.

Participant assumes Risk. Each Participant and his/her parent or guardian is aware of and understands the inherent risks and dangers, and the potential for injury that exists when participating in such activities with the program, and agrees to assume all risk of and responsibility for personal injury or death to, or damage to or loss of property of, the Participant arising from, based upon or relating to Participant’s participation in the
program. Such assumption of risk includes, but is not limited to, any personal injury or death, or damage to or loss of property, arising from, based upon or relating to the lack of skill of any participant, the improper conduct of any Participant and the acts or omissions of any supervisory person involved with program, and any personal injury or death, or damage to or loss of property, caused in whole or in part by the negligence of any affiliate of the Program. Each Participant and his/her parent or guardian understands and agrees that, in the event of any injury to Participant, the Program will not be responsible for any decisions relating to medical treatment for Participant nor for such treatment as may be required.

Right of Publicity. Participation in the program shall constitute permission to use the name, likeness or any other identification of the Participant for advertising, publicity, instructional or any other purposes in connection with the program, without compensation to or right of prior review or approval by the Participant or his/her parent or guardian. Participant and his/her parent or guardian agrees, for itself and its personal representatives, executors, administrators, heirs, next of kin and assigns, to release, discharge, and not to sue the Program, from any and all liabilities arising from, based upon or relating to any claim for invasion of privacy, violation of right of publicity, defamation or appropriation, or any similar
claim, in connection with any such use. This also includes that the child will or could be photographed for the purpose of this Program.

Representations:
By acknowledging below, each participant and his/her parent or guardian states that he/she understands and agrees to the above and that the participant is in good physical and mental condition, to participate in the program and is not subject to any medical condition that poses or may pose any risk or harm or disability to others.
 *
WISH LIST - These MUST be completed for your application to be considered. Include gifts for themselves, family, friends, pets and whoever else you see fit. Keep in mind that the child will have approximately $250 to spend, so the list should have enough items on it to spend that money. ABSOLUTELY NO GIFT CARDS can be listed, that includes money for games or apps that are purchased on gift cards. (Robucks, Fortnite $ etc.)

***IF YOU ARE LISTING CLOTHING OR SHOES PLEASE, pretty, pretty PLEASE INCLUDE THE SIZES AS WELL**

Lists that read "unsure" or "will pick out at the store" or have only a single item will result in the discarding of the entire application. 

We understand it can be difficult to think of these things ahead of time, but we must have this done to try and run a smoother event. 
LIST FOR CHILD #1 *
LIST FOR CHILD #2 or NA *
LIST FOR CHILD #3 or NA *
LIST FOR CHILD #4 or NA *
LIST FOR CHILD #5 or NA *
FOR OFFICIAL USE ONLY
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