SPOTSYLVANIA DEPARTMENT OF SOCIAL SERVICES
P. O. Box 249 Gail Crooks
Spotsylvania, VA 22553-0249 Director
540- 507-7898
9019 Old Battlefield Blvd Fax – 540-507-7806
Spotsylvania, VA 22553
VERY IMPORTANT, PLEASE READ IN FULL
Terms of Participation – CHILDREN AGES 2-16
The December holiday assistance program is intended to help children (ages 2 – 16) and adults (over age 60) who receive public assistance (different application). The Holiday Hope Program is not an entitlement program and you are not guaranteed to receive assistance. Assistance is provided as resources are available.
The Holiday Hope Program matches eligible applicants with citizens, church groups, and corporate sponsors. Government funds are not used for the purchase of Holiday Hope food items or gifts. While DSS works with sponsors to promote an appropriate understanding of the program and gifting practices, DSS is not responsible for incorrect sizes or non-age-appropriate items that may be received by the applicant.
A DSS staff member will contact you by December 8th if your household has been sponsored. Please DO NOT contact DSS prior to December 8th to ask if you have been matched with a sponsor. If you are sponsored, the pick-up dates and times will be as follows (look for appropriate signs):
You must follow these rules to participate in the Holiday Hope Program:
1. Applications will only be accepted October 16th – October 20th until 4:00pm.
2. Complete one application per family unit. A child should only be listed on one application. For caregivers sharing custody, only one parent or guardian can apply. Only list grandchildren, stepchildren or children for whom you have legal custody and reside in your home as their primary residence.
3. Be reasonable in requesting specific gifts. Requests for items such as video game systems, phones, laptops and tablets will not be honored. If requesting video games, please identify the game system. Please fill in size of shoes and clothing, and gift suggestion boxes.
4. Please give a complete address and working phone number where you can be reached. If you move or change phone numbers, contact the Holiday Hope Coordinator immediately with your new phone number and/or address. Failure to do so could result in your family not receiving holiday assistance.
5. DO NOT place your name or child’s name on any other holiday assistance lists.
Failure to follow any of the terms stated above will result in your application being denied and may disqualify you from future participation. Contact information Jackie Brett 540-507-7845, , Holiday Hope point of contact, if you have any questions or concerns.
______
Signature Date
REQUEST FOR DECEMBER HOLIDAY ASSISTANCE (2017)
Name of Applicant (parent name):______
Physical Address (where you live):______
Street
______
City Zip Code
Best Phone: ______Alt. Phone: ______Email: ______
Check the benefits that you receive at this time: SNAP (Food Stamps) Medicaid TANF
Please list ONLY the children in your house for whom YOU have legal custody of, on benefits & live with you:
Name Sex Age School Pants Shirt Shoe Gift Suggestions (identify game system)
Please you MUST list ALL adults living in the house age 18 & over including yourself:
1. ______3. ______
Full Name Sex Age Full Name Sex Age
2. ______4. ______
Full Name Sex Age Full Name Sex Age
I hereby certify that the information on this application is true and correct to the best of my knowledge and that I have read and agree to the terms of participation. My signature also serves as authorization to release the information contained herein. The above information will be shared with associated community agencies, schools, businesses and/or individuals, and placed on Charity Tracker which is available for viewing for a period 5 years. If I do not follow the terms of participation listed on the attached form, I understand that my application will be denied and I may be barred from future participation.
Signature: ______Date: ______
*** Both Pages Must Be Signed and Returned ***
An Equal Opportunity Agency