Senior Online Application

Criteria for Eligibility:
Must be 60+ years old AND alone* On Christmas (two eligible persons in same household may qualify).
*“Alone” means no one will be visiting you and you will not be visiting others (there are exceptions for Christmas Friendship Dinner or attending worship services).

The form should only be completed if you are eligible for the program. Any violation of the eligibility criteria may result in ineligibility for any future Santa Cop Christmas programs.

We do ask that you apply as soon as possible so our elves have time to do their shopping...er...building for your gifts. We want to have your information two weeks before Black Friday (Nov. 13).

If you feel more comfortable filling out a paper version of this form, click the green button below and then e-mail a scan of your completed form to: [email protected]

Download Print Version

Online Application

* Indicates required field

Name *

First

Last

Gender *

Male Female

Date of Birth *

Physical Address *

Line 1

Line 2

City

State

Zip Code

Country

Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Will you be home alone on Christmas Day? *

Yes No

When is the best time to visit? *

Emergency Contact Name *

Emergency Contact Phone Number *

If you are receiving assistance in filling out this form, pleas list their details here:

Name of Assistant *

Assistant Phone Number *

Wish List Suggestions

Please be as specific as possible.

Clothing (Type/Size) *

Footwear (Type/Size) *

Favorite Colors *

Household Items *

Craft/Hobby Items *

Music/Movies (Genre & Format) *

Other Non-Food Items *

Any Pets Owned? *

If dog owned, specify size: *

Small Medium Large Extra Large

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Online​Application

Online Application

Wish List Suggestions

Online
Application