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Love In the Name of Christmas 2023
Christmas application form
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* Indicates required question
Email
*
Your email
Parent/Guardian First Name
*
Your answer
Parent/Guardian Last Name
*
Your answer
Parent/Guardian Phone number
*
Your answer
Parent/Guardian Date of Birth
*
MM
/
DD
/
YYYY
Parent/Guardian Address
*
Your answer
Parent/Guardian City of Residency
*
Cushing
Yale
Drumright
Agra
Ripley
Other:
How many adults (18+) live in your home
*
0
1
2
3
4
5
Other:
Name and birthdate of
*
1
2
3
4
5
Other:
Would you or another adult in the home be interested in participating in one or more of the following classes?
Option 1
Clear selection
Do you/your children currently receive any of the following (check all that apply, verifications will be required for consideration)
Social Security Benefits
Sooner Care
Disability
Food Stamps
Other:
Are any of the children living in your home adopted, legally fostered, or under a DHS guardianship placement? (Verification will be required for consideration)
*
Yes
No
Other:
What is your employment status
*
Currently employed
Currently unemployed
Unemployed but receiving full disability benefits
Other:
A copy of your responses will be emailed to the address you provided.
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