Ukiah Valley Christmas Effort Application / Solicitud de esfuerzo navideño de Ukiah Valley
RETURNING THIS FORM DOES NOT GUARANTEE YOU WILL GET A PACKAGE 
P.O. Box 801, Ukiah, CA 95482  (707) 272-XMAS (9627)  ukiahchristmaseffort@yahoo.com

The Ukiah Valley Christmas Effort offers food for a Christmas dinner and gifts for the children of families in need. 
  • CHILDREN MUST LIVE IN THE HOME
  • YOU MUST BE HOME ON DECEMBER 24, 2022 (8:00 a.m. - 12:00 p.m.)
  • ONE APPLICATION PER FAMILY
  • LATE, INCOMPLETE, and DISHONEST APPLICATIONS MAY NOT BE CONSIDERED
  • DEADLINE: November 15, 2022
Please answer the following questions and include the income of ALL household members. Honesty is required.
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Total Monthly Income for Household? *
How Many Seniors (62+) In Your Household? *
How Many Adults (19+) In Your Household? *
How Many Teenagers in School (13–18) In Your Household? *
How Many Children (1–12) In Your Household? *
How Many Infants (under 1) In Your Household? *
Total People In Your Household? *
Do multiple Families Live In Your Household? *
Required
Parent/Guardian? *
Parent/Guardian 2? (optional)
Home Address? *
Telephone? (very important to include telephone numbers) *
Other Phone?
Mailing Address?
City? *
Do you live in a motel? *
Required
Do you have access to an oven? *
Required
Please tell us why you are in need this season. *
DEADLINE: November 15, 2022

YOU MUST BE HOME ON DECEMBER 24, 2022 
8:00 a.m. - 12:00 p.m.

Parent/Guardian Signature 
By typing your name here, you attest that all information in this form is accurate and true.
 *
List ALL children 18 years old and under in the family. 
Children MUST live in your home.
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