THE MOMMY NEST 2017 CHRISTMAS CARE PACKAGES APPLICATION
This form MUST be completed by November 19, 2017. There are NO EXCEPTIONS to this date. The application will be taken off the website after midnight on 11/19.
PLEASE READ EVERY SINGLE PART OF THIS BEFORE YOU PROCEED TO THE APPLICATION PART OR YOU WILL NOT BE FULLY INFORMED AND MAY RISK YOUR CHANCES OF BEING CHOSEN.
APPLICANTS MUST LIVE WITHIN 20 MILES OF LOUISVILLE, KY AND AGREE TO THE FOLLOWING STIPULATIONS
Only new families applying to our program will be considered. If your family has received assistance from us in the past, please do not apply as we do keep records and we will know if you have applied and received assistance previously. If you applied but did not receive assistance from us in the past, you are welcome to apply this year in the hopes that we may be able to pick you. We have to make sure we are helping new families each and every year and we want to spread our help out as much as possible.
Only 1 application per family will be accepted. If parents are divorced, only one parent should fill out an application for their children’s needs as we will not gift both parents with the same things twice.
Please complete all information requested. Information is to be listed only for those family members residing in the home. You may fill in all of the application, but please know that at this time we mostly only have Children’s toys to donate and we will mostly specifically only be looking to gift items for Children ages 2-10. Please understand that we do our best to gift your children with new items but we do sometimes gift you with gently used items if we feel as though they are in very good condition.
We would prefer that you list your top priorities for toys for children first before listing other household members or children above the age of 10. Please understand that we may only be able to fill a few requests from your application. The odds of us being able to gift you with electronics, gift cards, or expensive items are slim. We also can’t help purchase specific items for your children like clothing needs unless you include very specific information on sizes, colors, etc. For instance, if you list that they really needs jeans and shoes, please be very specific on what sizes, like 5 slim or 10 Husky and toddler shoe size 10 or Youth shoe size 2. The more info you can give us the better chance you have of getting items you can actually use/want. It is best for you to give a lot of info for clothing type items but keep toy requests more broad as we often times have to choose from toys that have already been donated and have to go with toys that are just simply age or interest appropriate. So, for instance if you have a 4 year old girl, you may put things like, she loves dress up, dolls, and drawing. This gives us an idea of her interests and helps us choose a few items that are appropriate. You are welcome to list specific items that are truly desired but keep an open mind that we may only be able to gift a few things and we may not be able to do specific items.
EXAMPLE OF HOW TO FILL IN EACH CHILD:
Additional Household Member
Relationship to Head of Household: Daughter
Last 4 of Social: 1234
First Name: Jane
Last Name: Doe
Item 1: Dolls
Item 2: Books
Item 3: Winter Coat – Size 6T
Item 4: Jeans – Size 6 Slim
We do include an area for “Head of Household” wishlist, this would be a space for you to let us know if you need food, household cleaning supplies, etc. This is not an area where you should list items you want, but only items you are truly in need of. Again, we are sorry but we are not an organization who has the resources to help with everything and our focus is on toys for your children.
There is no guarantee that you will receive assistance just because you have filled out an application.
You will be required to sign an agreement and liability release upon acceptance of items.
Applicants who are accepted will receive an email letting them know that they have been accepted sometime between 11/20 – 12/17. Please do not email us asking for an update. Check your email regularly to see if you get a confirmation number from us. We do apologize ahead of time, but we cannot accept every application that comes in. We do our very best based on the donations we receive.
Applicants must be willing and able to meet us to pick up their donations. Applicants will receive specific details on dates and places that are the options for pickup up as there will be a few. We do not offer delivery and cannot arrange other times to meet you. You must check your email regularly. If you are chosen and do not respond to your confirmation email within 5 days, we will have to move on to another family. Only applicants with a confirmation email of acceptance will be allowed to pick-up. We would prefer there be NO CHILDREN when you pick-up as we can’t always guarantee that things can be “hidden” but we will leave it up to you.
*All personal information will be kept confidential and will only be used to determine eligibility.
*Family need and resources available will determine eligibility
*I understand that completing this application does not guarantee the receipt of any gifts or food, and that the quality and quantity of gifts is dependent upon the generosity of donors. I understand that some items are gently used.
Last 4 of Social Security Number
Number of people in Household
Number of Children in Household
Date of Birth
Primary Language Spoken
Check if Attending School
You must check one sentence in each category. Regardless of your indications, all applicants will be considered equally. By indicating your situation in certain areas we may better be able to determine where you need the most help that we can provide.
Have you received Christmas assistance from The Mommy Nest before?
I can provide food and clothing for my family
I sometimes need help from assistance programs for food, clothing and household items
I regularly use assistance programs for food, clothing and household items
I have a steady source of income and/or my job is not in jeopardy
I sometimes need financial assistance
I have no steady income and regularly use public benefits (TANF, Food Stamps, Unemployment, etc)
I have no income and limited or no public benefits
I have stable and adequate housing
Short term help is needed at times to remain in adequate housing
Overcrowded or substandard living conditions, I may be evicted soon
Homeless or Recent eviction or living in a shelter or living with family/friends due to financial need
I will receive Christmas help from another program or family
I may receive limited Christmas help through others, but unknown at this time
I will not receive Christmas help through any other means
I or someone in my family needs regular medical treatment. Please list family member and active medical condition.
I or someone in the family has special needs or disability. Please list family member and need/disability.
I or someone in the family uses mental health services regularly.
I have adequate transportation
Family only has one vehicle which is primarily used work transportation
I carpool or take the bus most days
Household member homebound
Employed full time
Employed part time
Attend school full time
Attend school part time
Total Household Income
$25,000 to $40,000
$40,000 to $65,000
Other information that may demonstrate the need for assistance. For example: Lost 50% of income due to layoff.
Please know that we do sometimes give you very gently used clothing, shoes, coats, or toys as we often times get wonderful donations that could be available. If your child has some sort of allergy or health concern that we need to be aware of, please list it, otherwise, know that you may receive gently used items. Requests for Wii, PlayStation, IPod, and other expensive items are not acceptable. Gift cards will not be available so please do not list them. Our goal is to give items that are age and gender appropriate. Ethnicity indicated below is for toy purchase purposes and is not a required field. However, if you would really like for your child to have an African American doll or a Hispanic character themed toy, you need to list that or we will not know!
If you have a priority for CLOTHING either for yourself or your children, please place that in the 3-4 items lineup where it falls and give us SPECIFICS on sizes. We can’t attempt to have the correct clothing, coat, pj, or shoe sizes there for you to choose from if we don’t have an idea ahead of time of your needs. For Example, if you have a small 5 year old girl, your request list for her may look like this:1) Baby Doll2) Winter Coat – Size 4t3) Coloring books and crayons4) Girl’s Jeans – size 4t slimAre you willing to accept gently used Clothing, Shoes, Coats, etc.? YESAre you willing to accept gently used toys? NO
Is this person willing to accept gently used Clothing, Shoes, Coats, etc.?
Relationship to Head of Household
Last 4 of Social Security Number
Is this person willing to accept gently used toys?
I understand that completing this application does not guarantee the receipt of any gifts or food, and that the quality and quantity of gifts is dependent upon the generosity of donors.
I acknowledge that I am applying for Christmas assistance of my own free will and releasing personal information to The Mommy Nest Board of Directors solely for this purpose. By doing this I understand that with any electronic data there is always a potential risk of unauthorized access and I HEREBY ASSUME THE RISKS OF SUCH ACCESS.
I hereby take the following action for myself, my executors, administrators, heirs, next of kin, successors and assigns: a) I WAIVE, RELEASE, AND DISCHARGE from any and all claims or liabilities for death or personal injury or damages of any kind, EXCEPT THAT WHICH IS THE RESULT OF GROSS NEGLIGENCE AND/OR WANTON MISCONDUCT OF PERSONS OR ENTITIES LISTED BELOW, which arise out of my participation in The Mommy Nest Christmas Care Package program, THE FOLLOWING PERSONS OR ENTITIES:
The Mommy Nest, The Mommy Nest Board of Directors and the officers, directors, employees, representatives, and agents of any of the above; b) I AGREE NOT TO SUE any of the persons or entities listed above for any of the claims or liabilities that I have waived, released or discharged herein; and c) I INDEMNIFY AND HOLD HARMLESS the persons or entities mentioned above from any claims made or liabilities assessed against them as a result of my actions.
If your application was accepted, or if we need more details, we will contact you within 2-4 weeks.
The Mommy Nest