Short Term Emergency Aid Committee · 2021 Holiday Program

Number of people in your household

*

Did you participate in this program in 2020?

*

Yes

No

Applicant Information

You must live in Davis to participate in the Holiday Program. If you are not a Davis resident, please do not fill out and submit this form.

Home Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Alert

You must live in Davis to participate in the Holiday Program.
If you are not a Davis resident, please do not fill out and submit this form.

Email

*

IMPORTANT: Please proved an email address that you will be checking. This is where your Program ID# and pick-up instructions will be sent from holidayprogram@steac.org after you have been approved.

Verify Email

*

Phone

*

Please provide a phone number that can receive text messages.

OK to send texts to this phone number?

*

Yes

No

ADULTS in Household

Number of Adults 18 years and older

*

This form allows entry of up to 4 adults in each household. If there are 5 or more adults living in your household, please enter them under "Children (Age 17 years and younger)" below.

Primary Applicant and Co-Applicant

#1 PRIMARY ADULT APPLICANT

*

First Name

Last Name

ADULT # 2 IN HOUSEHOLD

*

First Name

Last Name

#1 Primary Adult Relation

*

Single

Head of Household

Grandparent

Other

Adult #2 Relation to Primary Applicant

*

Spouse

Parent

Son or Daughter

Other

#1 Primary Adult Gender

*

Male

Female

Decline to State

Adult #2 Gender

*

Male

Female

Decline to State

#1 Primary Adult Date of Birth

*

(mm/dd/yyyy)

Adult #2 Date of Birth

*

(mm/dd/yyyy)

#1 Primary Adult - Source of Income

*

Adult #2 - Source of Income

*

#1 Primary Adult - GROSS Income per Month

*

$$

Adult #2 - GROSS Income per Month

*

$$

Your adopter will be asked to provide one-or-more gifts for each person totalling ~$30. Please provide some gift ideas and be sure to include helpful information like size, color preference, etc. (e.g. "Men's polo-style long-sleeved shirt size Large in green or blue" or "Infinity Scarf in any color"). Adopters overwhelmingly prefer to buy & wrap gifts, so at most, only one of the lines should be a gift card.

#1 Primary Adult - 1st Gift Idea

*

Adult #2 - 1st Gift Idea

*

#1 Primary Adult - 2nd Gift Idea

*

Adult #2 - 2nd Gift Idea

*

Other Adults in Household

Adult #3 in Household

*

First Name

Last Name

Adult #4 in Household

*

First Name

Last Name

Adult #3 Relation to Primary Applicant

*

Spouse

Parent

Son or Daughter

Other

Adult #4 Relation to Primary Applicant

*

Spouse

Parent

Son or Daughter

Other

Adult #3 Gender

*

Male

Female

Decline to State

Adult #4 Gender

*

Male

Female

Decline to State

Adult #3 Date of Birth

*

(mm/dd/yyyy)

Adult #4 Date of Birth

*

(mm/dd/yyyy)

Adult #3 - Source of Income

*

Adult #4 - Source of Income

*

Adult #3 - GROSS Income per Month

*

$$

Adult #4 - GROSS Income per Month

*

$$

Adult #3 - 1st Gift Idea

*

Adult #4 - 1st Gift Idea

*

Adult #3 - 2nd Gift Idea

*

Adult #4 - 2nd Gift Idea

*

CHILDREN (Age 17 years and younger)

Number of Children 17 years old and younger

*

If you have more than 8 children in your household

This form allows entry of up to 8 children in each household. If there are 9 or more children living in your household, please submit this form for 8 children, and then send an email to holidayprogram@steac.org to get the other children registered.

#1 Child Name

*

First Name

Last Name

#2 Child Name

*

First Name

Last Name

#1 Child's Relation to Primary Applicant

*

Son or Daughter

Grandchild

Other

#2 Child's Relation to Primary Applicant

*

Son or Daughter

Grandchild

Other

#1 Child Gender

*

Male

Female

Decline to State

#2 Child Gender

*

Male

Female

Decline to State

#1 Child Date of Birth

*

(mm/dd/yyyy)

#2 Child Date of Birth

*

(mm/dd/yyyy)

Your adopter will be asked to provide one-or-more gifts for each person totalling ~$30. Please provide some gift ideas and be sure to include helpful information like size, color preference, etc. (e.g. "Pink pajamas with kittens or puppies in size 3T" or "Hot Wheels Cars and Storage Case"). Adopters overwhelmingly prefer to buy & wrap gifts, so at most, only one of the lines should be a gift card.

#1 Child - 1st Gift Idea

*

#2 Child - 1st Gift Idea

*

#1 Child - 2nd Gift Idea

*

#2 Child - 2nd Gift Idea

*

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

#3 Child Name

*

First Name

Last Name

#4 Child Name

*

First Name

Last Name

#3 Child's Relation to Primary Applicant

*

Son or Daughter

Grandchild

Other

#4 Child's Relation to Primary Applicant

*

Son or Daughter

Grandchild

Other

#3 Child Gender

*

Male

Female

Decline to State

#4 Child Gender

*

Male

Female

Decline to State

#3 Child Date of Birth

*

(mm/dd/yyyy)

#4 Child Date of Birth

*

(mm/dd/yyyy)

#3 Child - 1st Gift Idea

*

#4 Child - 1st Gift Idea

*

#3 Child - 2nd Gift Idea

*

#4 Child - 2nd Gift Idea

*

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

#5 Child Name

*

First Name

Last Name

#6 Child Name

*

First Name

Last Name

#5 Child's Relation to Primary Applicant

*

Son or Daughter

Grandchild

Other

#6 Child's Relation to Primary Applicant

*

Son or Daughter

Grandchild

Other

#5 Child Gender

*

Male

Female

Decline to State

#6 Child Gender

*

Male

Female

Decline to State

#5 Child Date of Birth

*

(mm/dd/yyyy)

#6 Child Date of Birth

*

(mm/dd/yyyy)

#5 Child - 1st Gift Idea

*

#6 Child - 1st Gift Idea

*

#5 Child - 2nd Gift Idea

*

#6 Child - 2nd Gift Idea

*

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

#7 Child Name

*

First Name

Last Name

#8 Child Name

*

First Name

Last Name

#7 Child's Relation to Primary Applicant

*

Son or Daughter

Grandchild

Other

#8 Child's Relation to Primary Applicant

*

Son or Daughter

Grandchild

Other

#7 Child Gender

*

Male

Female

Decline to State

#8 Child Gender

*

Male

Female

Decline to State

#7 Child Date of Birth

*

(mm/dd/yyyy)

#8 Child Date of Birth

*

(mm/dd/yyyy)

#7 Child - 1st Gift Idea

*

#8 Child - 1st Gift Idea

*

#7 Child - 2nd Gift Idea

*

#8 Child - 2nd Gift Idea

*

More than 8 children?

This form allows entry of up to 8 children in each household. If there are 9 or more children living in your household, please submit this form for 8 children, and then send an email to holidayprogram@steac.org to get the other children registered.

Grocery List Selection

Your "adopter" will be providing food for you based on a suggested list of food items. There are three choices for you to select from. They are: A (Traditional American) or B (Hispanic-Inspired) or C (Asian-Inspired). At the top of this form there is a link to view each list.

Food List Choice

*

A - Traditional List

B - Hispanic-Inspired

C - Asian-Inspired

Application Confirmation and Approval

A volunteer from STEAC will be calling you to confirm your application. Please be prepared to provide the following:

Proof of residency in Davis: current lease or rent receipt or another recently dated bill with your name and Davis address (i.e. PG&E, phone bill, etc.). These documents must be dated within the last two months.
Income verification (one or more of the following): current paycheck stubs of everyone in your household who earns money, FREE School Lunch Program eligibility letter, Public Assistance printout (i.e. CalWorks or SA), and/or UI, SSDI, or SSI (need award letter; BIC card alone is not acceptable).
Identification for each family member: Social Security cards, birth certificates, school IDs, California IDs, California driver’s license, passport, or international picture ID.

Preferred Call Back Day and Time

You may select as many as you'd like, but space is limited so you will want to be approved as early as possible.

Select from these dates and times

*

Monday, November 15 between 10am-1pm

Preferred Type of Phone Call

*

We are only offering Voice Call Backs. We will call you at the phone number provided at the top of this form during your selected callback window.

Voice Call

Language Preference

*

We try very hard to have volunteers who speak Spanish and Mandarin for each of our callback windows, but cannot always guarantee it. Let us know your language preference below, but if possible, please try to have a translator with you for the phone call from the STEAC Volunteer.

English

Spanish

Mandarin

Any Additional Comments you would like to share with STEAC?

Statement of Accuracy

I certify that the information submitted in this application is true and correct to the best of my knowledge.

I further understand that any false statements or willful dishonesty may result in denial or revocation of qualification for the Holiday Program and other STEAC Services.

Please click on Yes to confirm.

*

Yes

Full Name of Primary Applicant

*

Please type in your FULL Name.

**ALERT**

THE 2021 HOLIDAY PROGRAM HAS REACHED FULL CAPACITY.
WE ARE CURRENTLY ACCEPTING APPLICATIONS ON A WAITLIST-BASIS ONLY.

2021 STEAC Holiday ProgramAdoption Application

Applicant Information

You must live in Davis to participate in the Holiday Program.If you are not a Davis resident, please do not fill out and submit this form.

ADULTS in Household

Primary Applicant and Co-Applicant

Other Adults in Household

CHILDREN (Age 17 years and younger)

Grocery List Selection

2021 STEAC Holiday Program
Adoption Application

You must live in Davis to participate in the Holiday Program.
If you are not a Davis resident, please do not fill out and submit this form.