Christmas 2024 Assessment Form

Do you Consent to the above Privacy Policy for the purposes of this enquiry: * Yes No

Title: * Mr Mrs Ms Miss Other

Are you a Parent or Grandparent: * -- Please Select -- Parent Grandparent

First Name: *

Last Name: *

Date of Birth: *

Contact Number: *

Email Address: *

Current Residential Address : *

Suburb: *

State: *

Postcode: *

Country of Birth: *

Residency Status: * -- Please Select -- Citizen / Permanent Resident Asylum Seeker Humanitarian (Refugee) International Student Migrant Temporary Protection Tourist / Visitor Worker (e.g. Sponsored) Other

Main Language Spoken: *

Indigenous Status: * -- Please Select -- None Aboriginal but not Torres Strait Islander Torres Strait Islander but not Aboriginal Aboriginal and Torres Strait Islander

Do you have a Disability: * -- Please Select -- None Identified Intellectual Learning Sensory / Speech Psychiatric Physical / Diverse

Are you currently experiencing Financial Hardship: * Yes No

What has caused your Financial Hardship:

Are you being referred by a Caseworker from another Organisation: * Yes No

Who are you being referred by: * -- Please Select -- Catholic Care Mission Australia St Vincent De Paul Centrelink Salvos Stores Family Member / Friend Self

Are you receiving assistance from any other organisation for Christmas: * Yes No

Who is providing the assistance and what assistance is being provided?: *

How many children do you have (The children must be listed on your ID): * 0-2 2-5 5+

Name of Child / Grandchild: *

Gender: * Boy Girl

Date of Birth: *

Name of Child / Grandchild:

Gender: Boy Girl

Date of Birth:

Name of Child / Grandchild:

Gender: Boy Girl

Date of Birth:

Name of Child / Grandchild:

Gender: Boy Girl

Date of Birth:

Name of Child / Grandchild:

Gender: Boy Girl

Date of Birth:

Current Centrelink Statement: *

Bank Statement for last 3 Months: *

ID showing current address: *

ID such as Centrelink or Medicare showing Children's Details: *

Payslip (if working): *

How did you hear about Christmas Assistance: * -- Please Select -- Social Media Have received assistance in prior years Hornsby Corps Website Referral from outside agency Word of Mouth Referral from Salvation Army