Depoe Bay Fire District
Holiday Basket Application

HOLIDAY BASKET APPLICATION

Sponsored by the Depoe Bay Fire District and Chester’s Markets

*Please note, if application is for a multi-family home, each family must complete a separate application.

APPLICANT INFORMATION

Last Name

First Name

M.I.

Street Address

Apartment / Unit #

City

State

Zip

Phone

Email Address

# of Children

# of Adults

Total in Home

Children’s School(s)

Have you applied for any other Holiday Assistance Programs or Holiday Basket Program?

Yes ?

No ?

If Yes, where/what programs?

Does more than 1 family live in this home?

Yes ?

No ?

If Yes, have they completed an Application?

Yes ?

No ?

Please provide First Name, Age, Gender and Clothing Size for each child who resides in your home.  Please list 1 request per child of an item valued under $25. Gift requests are not guaranteed of delivery.  Each gift is subject to available items. 

Please use the area labeled “Notes” to alert our volunteers of any special needs for each child (example: Disability, Food Allergies, etc.) *If you need additional sections please attach a piece of paper.

CHILDREN

Name

Age

Clothing Size

Request

Gender

Notes

Name

Age

Clothing Size

Request

Gender

Notes

Name

Age

Clothing Size

Request

Gender

Notes

Name

Age

Clothing Size

Request

Gender

Notes

Name

Age

Clothing Size

Request

Gender

Notes

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

I understand that this application does not guarantee assistance and I will not be notified of my application status.

I have read the eligibility requirements and I certify that I currently reside in the geographic boundaries and I will not be moving prior to delivery. 

I understand that an adult over the age of 18 who is listed on this application must pick up the Holiday Basket on Saturday, December 19, 2020, between 10:00 am and 1:00 pm at the Gleneden Beach Fire Station (6445 Gleneden Beach Loop, Gleneden Beach, OR  97388).

If I am unable to pick up the Holiday Basket, I forfeit my right to assistance.

Signature

Date

Additional Notes for Volunteers:

Program Information:

Applicants MUST reside within the Depoe Bay Fire District including Siletz Keys, Gleneden Beach, Lincoln Beach, Depoe Bay and Otter Rock.

Application address is the primary residence for a child or children under the age of 18 years.

Applications reviewed based on need and availability of resources. Applications do not guarantee a basket.

Applications must be submitted no later than December 9, 2020, at 5:00 pm, and must be turned into one of the following locations:

  • Depoe Bay Fire Station
  • Chester’s Market, Lincoln Beach
  • Taft 7-12 and Taft Elementary (Attn: Sandie Tucker)

Application Received Date:

Application Received By:

Application Status:


  • Depoe Bay Fire District

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