Holiday Angels Program 2019 Holiday Angels ProgramsWe are grateful to be able to share our Holiday Angels program with you. This program is intended for Living Beauties with a special need and/or who need some extra help during this holiday season. Please fill out the application to the best of your ability. Applications will be reviewed soon. First Name * Last Name * Mailing Address 1 * Mailing Address 2 City * State * - select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUnited States Minor Outlying IslandsUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Postal Code * Phone * Email * Date of your most recent diagnosis? * Approximate Annual Household Income *$25K or less$25-40K$40-60K$60-80K$80-100K$100K + Has your cancer impacted your household income? * - select -No. Income has not been impacted.Yes. Income dropped 25%Yes. Income dropped 26-50%Yes. Income dropped 51-75%Yes. Income dropped 76-100% Source of Income (Select Range) * Wages from work Unemployment Disability Social Security Income from a partner who is part of household Child/Spousal support Other How many people are in your household? * Other things we should knowPlease list the names of your family members along with their wishlist, clothing size and any other notes. Family Member Wishlist Please only fill out this question if you'd like to be considered for a holiday meal gift card. Yes, please consider providing a gift card for a holiday meal. My closest market is: Please consider providing us with a Christmas Tree Yes No, we're okayI confirm that, to the best of my knowledge, the above information is true. I give my consent to the determination committee to review my personal information, as part of the decision-making process. Applicant Signature * Applicant Signature Date of Application * Acknowledgement * By clicking this box and signing below I am indicating the funds will be used as requested above
