Your Name (required) Your Address (required) Phone Number (required) Your Email (required) Have you or anyone in your household applied for or requested Christmas assistance at any other locations? YesNo Do you or anyone in your house hold receive or have any of the following (circle all that apply) Sickle CellUnemploymentFood StampsTemporary AssistanceSocial SecurityOther If Other please explain Child/Children's Name Child One Age Gender BoyGirl Child Two Age Gender BoyGirl Child Three Age Gender BoyGirl All Applications must be mailed or Submitted by November 1, 2019 Mailing Address: 91 P.O. Box Ramapo Road Garnerville N.Y. 10923 Number: (845) 947-8542