Applications Now Accepted For

16th Annual Santa For Seniors Drive

Those wishing to submit a name for the 16th Annual Santa for Seniors Christmas drive, may do so by filling out the following form. Santa For Seniiors is an annual effort to provide necessities and Christmas gifts for senior citizens and shut-ins throughout Lawrence County.

Forms MUST BE RECIEVED no later than Monday, December 10th, 2012.*Note that physical address MUST be listed. Please fill form out as completely as possible then submit. Thank you.

Recipients Name
	Please fill out as much information as possible.
Sex: "Male" or "Female"
Diabetic: "Yes" or "No"

I will have someone pick up my package on Thursday, Dec. 13 at WLX, 1212 North Locust Ave. Between 12noon and 3pm. Yes or No

Age
Address
Clothing Size
Shoe Size
Phone Number
Special Needs
Other Comments
If you live in apartment, name of complex please

Directions to home. This is VERY important.
Be sure to click "Submit" button when finished.