CHESTERFIELD-COLONIAL HEIGHTS CHRISTMAS MOTHER FAMILY APPLICATION

An asterisk (*) means the question is required.

Resident of (Select one) *

Chesterfield

Colonial Heights

Military/Veteran (Y/N) *

Yes

No

Branch of Service

Race (Select one) *

American Indian

Asian

Black/African American

Hispanic/Latino

White

Other

Not Stated

Applicant Last Name *

Applicant First Name *

Applicant Middle Initial

Applicant Date of Birth *

Applicant SSN/Tax ID *

Spouse/Co-Hab Last Name

Spouse/Co-Hab First Name

Address

Street Address *

City *

Postal Code *

Apt./Lot #

Email *

Phone *

How many people live in your household, including yourself? *

In 2024 or 2025, did you pick up gifts from Christmas Mother, or did you shop for the gifts yourself? *

Do your children reside with you?

Yes

No

Are any of them Grandchildren

Yes

No

If any of these children are not yours, do you have legal custody and custody papers? (Y/N)

Yes

No

How many children reside with you?

Select an option

Child 1 Name

Child 1 Gender

Male

Female

Child 1 Date of Birth

Child 1 SSN or Tax ID #

Name of School Child 1 Attends

Child 2 Name

Child 2 Gender

Male

Female

Child 2 Date of Birth

Child 2 SSN or Tax ID #

Name of School Child 2 Attends

Child 3 Name

Child 3 Gender

Male

Female

Child 3 Date of Birth

Child 3 SSN or Tax ID #

Name of School Child 3 Attends

Child 4 Name

Child 4 Gender

Male

Female

Child 4 Date of Birth

Child 4 SSN or Tax ID #

Name of School Child 4 Attends

Child 5 Name

Child 5 Gender

Male

Female

Child 5 Date of Birth

Child 5 SSN or Tax ID #

Name of School Child 5 Attends

Child 6 Name

Child 6 Gender

Male

Female

Child 6 Date of Birth

Name of School Child 6 Attends

Child 7 Name

Child 7 Gender

Male

Female

Child 7 Date of Birth

Name of School Child 7 Attends

Child 8 Name

Child 8 Gender

Male

Female

Child 8 Date of Birth

Name of School Child 8 Attends

Child 9 Name

Child 9 Gender

Male

Female

Child 9 Date of Birth

Name of School Child 9 Attends

Child 10 Name

Child 10 Gender

Male

Female

Child 10 Date of Birth

Name of School Child 10 Attends

Do you receive SNAP benefits? *

Yes

No

Monthly Income Before Taxes

Your Employer: *

TOTAL Monthly Household Income (including child support) *

Additional Comments *

I hereby give my consent for the Chesterfield-Colonial Heights Christmas Mother program to make any inquiries to determine my need for help and to share the information on this application with other charitable organizations. I have not and will not ask for help from any other organization for Christmas. *

Clear

WISH LIST FOR CHILDREN - Please Note: A Wish List item is not a guarantee you will receive the item

Child 1 First Name

Child 1 Gender/Height/Weight

Child 1 Age

Child 1 Large Gift (Up To $50)

Child 1 Small Gift 1 (Less Than $25)

Child 1 Small Gift 2 (Less Than $25)

Clothing

For Clothing please specify size Ex. Little Boys sz 5 Teen Boy - Men’s sz L, Teen Girl - Junior sz 9 or Women sz 14, Infant size 6 mos. Toddler size 3T, For socks, ex. Boys 5/Ankle sock

Child 1 Pants Size

Child 1 Shirt/Blouse Size

Child 1 Sock Size/Type

Child 1 Favorite Color

Child 1 Underwear/Size/Type

Child 1 Book Suggestions

Child 2 First Name Only

Child 2 Gender/Height/Weight

Child 2 Age

Child 2 Large Gift (Up To $50)

Child 2 Small Gift 1 (Less Than $25)

Child 2 Small Gift 2 (Less Than $25)

Child 2 Pants Size

Child 2 Shirt/Blouse Size

Child 2 Sock Size/Type

Child 2 Favorite Color

Child 2 Underwear/Size/Type

Child 2 Book Suggestions

Child 3 First Name Only

Child 3 Gender/Height/Weight

Child 3 Age

Child 3 Large Gift (Up To $50)

Child 3 Small Gift 1 (Less Than $25)

Child 3 Small Gift 2 (Less Than $25)

Child 3 Pants Size

Child 3 Shirt/Blouse Size

Child 3 Sock Size/Type

Child 3 Favorite Color

Child 3 Underwear/Size/Type

Child 3 Book Suggestions

Child 4 First Name Only

Child 4 Gender/Height/Weight

Child 4 Age

Child 4 Large Gift (Up To $50)

Child 4 Small Gift 1 (Less Than $25)

Child 4 Small Gift 2 (Less Than $25)

Child 4 Pants Size

Child 4 Shirt/Blouse Size

Child 4 Sock Size/Type

Child 4 Favorite Color

Child 4 Underwear/Size/Type

Child 4 Book Suggestions

Child 5 First Name Only

Child 5 Gender/Height/Weight

Child 5 Age

Child 5 Large Gift (Up To $50)

Child 5 Small Gift 1 (Less Than $25)

Child 5 Small Gift 2 (Less Than $25)

Child 5 Pants Size

Child 5 Shirt/Blouse Size

Child 5 Sock Size/Type

Child 5 Favorite Color

Child 5 Underwear/Size/Type

Child 5 Book Suggestions

Child 6 First Name Only

Child 6 Gender/Height/Weight

Child 6 Age

Child 6 Large Gift (Up To $50)

Child 6 Small Gift 1 (Less Than $25)

Child 6 Small Gift 2 (Less Than $25)

Child 6 Pants Size

Child 6 Shirt/Blouse Size

Child 6 Sock Size/Type

Child 6 Favorite Color

Child 6 Underwear/Size/Type

Child 6 Book Suggestions

Child 7 First Name Only

Child 7 Gender/Height/Weight

Child 7 Age

Child 7 Large Gift (Up To $50)

Child 7 Small Gift 1 (Less Than $25)

Child 7 Small Gift 2 (Less Than $25)

Child 7 Pants Size

Child 7 Shirt/Blouse Size

Child 7 Sock Size/Type

Child 7 Favorite Color

Child 7 Underwear/Size/Type

Child 7 Book Suggestions

Child 8 First Name Only

Child 8 Gender/Height/Weight

Child 8 Age

Child 8 Large Gift (Up To $50)

Child 8 Small Gift 1 (Less Than $25)

Child 8 Small Gift 2 (Less Than $25)

Child 8 Pants Size

Child 8 Shirt/Blouse Size

Child 8 Sock Size/Type

Child 8 Favorite Color

Child 8 Underwear/Size/Type

Child 8 Book Suggestions

Child 9 First Name Only

Child 9 Gender/Height/Weight

Child 9 Age

Child 9 Large Gift (Up To $50)

Child 9 Small Gift 1 (Less Than $25)

Child 9 Small Gift 2 (Less Than $25)

Child 9 Pants Size

Child 9 Shirt/Blouse Size

Child 9 Sock Size/Type

Child 9 Favorite Color

Child 9 Underwear/Size/Type

Child 9 Book Suggestions

Child 10 First Name Only

Child 10 Gender/Height/Weight

Child 10 Age

Child 10 Large Gift (Up To $50)

Child 10 Small Gift 1 (Less Than $25)

Child 10 Small Gift 2 (Less Than $25)

Child 10 Pants Size

Child 10 Shirt/Blouse Size

Child 10 Sock Size/Type

Child 10 Favorite Color

Child 10 Underwear/Size/Type

Child 10 Book Suggestions

SMS Consent (Family Application)

I consent to receive non-marketing text messages from CCH Christmas Mother about my application status, scheduling, pickup or delivery details, volunteer shifts, and sponsor coordination. Message frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.