Apply for Holiday Help — Elderly/Disabled Household

You will receive your gifts in the mail.

Your answers are private. We use them only to prepare your family's gifts, and we never share your name with donors or sponsors without your permission.

Rather not do this online? That's just fine:

Call our message line at 608-723-2136 ext 1194 and we'll mail you a paper application.
Or print the paper application and mail it back to the address printed on the form.

Please apply to only one holiday project in Grant County. Applicant names are shared among the county's projects, so applying in more than one place can hold up your gifts.

About you

First name

Last name

Street address

Town

Phone number

Email address (optional)

Type your email again

Which describes your household?

Someone here is 65 or older Someone here is permanently disabled and receives Social Security or SSI

People in your household

Tell us about everyone who lives with you, starting with yourself as Person 1. Sometimes the household is a couple and both are elderly — if that's you, just add another person below. Each person's income, like Social Security or SSI, has its own place in the Benefits section further down.

Person 1 — you

First and last name

Age

Work and income

Please list all money coming into your home — even small or occasional amounts like babysitting, odd jobs, or in-home care. Listing everything helps us help you faster.

Please list every job in your household — we're required to ask. If no one is working right now, just check the box below.

Job 1

Employer's name

Who works this job?

Hourly wage (dollars)

Hours worked per week

No one in our household is currently employed

Benefits

These questions cover everyone in your household — you and each person you listed above.

For each one: enter the total amount your household receives, and under "Who receives it?" write the name of each person it comes for — that's how we know who receives Social Security or SSI. If nobody here receives it, check "we don't receive this." You never have to guess — your award letters have these numbers.

Food Share

Monthly amount (dollars)

We don't receive this

Social Security

Monthly amount (dollars)

Who receives it?

We don't receive this

SSI

Monthly amount (dollars)

Who receives it?

We don't receive this

Child support

Monthly amount (dollars)

Who receives it?

We don't receive this

Unemployment

Weekly amount (dollars)

Who receives it?

We don't receive this

Other income

Monthly amount (dollars)

Who receives it?

We don't receive this

Years of help

How many years have you received help from the Holiday Project? (enter 0 if this is your first year)

Pay it forward

The Holiday Project runs on kindness, and everyone has some to give. To receive gifts, we ask you to share one act of kindness you've done in your community — things like shoveling a neighbor's snow, giving someone a ride, or visiting someone who's lonely. (Helping your own family, or work you're paid for, doesn't count for this — the idea is to reach someone new.)

Tell us about one good deed you've done