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Willie 103.5's Great Christmas Give Back
Please completely fill out the form below. We appreciate your application!
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All contents of this form and your application will be held in complete confidence and anonymity. Your identity will never be published, broadcast or printed in any way, shape or form; even if you are selected as the recipient of the GiveBack.
Your Full Name
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Your answer
Best Phone Number
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Your answer
Do you accept text messages at above number?
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Yes
No
Best Email Address
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Your answer
Who are you nominating?
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My Own Family
A Family I know
If you are nominating a family, other than your own, please provide the parent(s) name(s).
Your answer
Are you (or the family you're nominating) employed? (Choose answer that best describes employment status)
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Family has two parents. Both parents are employed.
Family has two parents. Only one parent is employed.
Family has two parents. Neither parent is employed.
Family has one parent. Single parent is not employed.
Family has one parent. Single parent is employed.
Unsure.
What is the range of your (or family you are nominating) household income on a typical basis?
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Less than $30,000 per year
$30,000 - $60,000 per year
$60,000 - $90,000 per year
Over $90,000 per year
Unsure
Please list the name and age of each child in household:
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Your answer
Please tell us your story. Be as detailed or brief as you choose. Be sure to tell us why you think the Christmas GiveBack would bring joy to this family.
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Your answer
Are you able to help coordinate a 'surprise' for the family?
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Yes
No
Maybe
Due to the nature of this opportunity, we seek anonymity for all involved parties. Confidentiality is kept at the highest level.
I agree.
I do not agree.
Our selection committee will review all applications in confidence. Recipients will be contacted personally using the contact methods provided above. While we wish that we could help every family who applies, it is simply impossible. Thank you for your application and Merry Christmas!
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