United Way of
Rockland County

Hope for the Holidays Form

Please fill out the information below and submit by November 9th, 2018. You must submit information for EACH family member.

Please note, efforts will be made to fulfill requests, however, there is no guarantee that all requests will be met.



Date:    

Person Completing Request Name:    

Person Completing Request Phone (e.g. 845-123-4567):    

Agency of Person Completing Request::    


Family Situation/Why is Assistance Needed?:

Individual's Name:    

Age:     Gender:     Male     Female    

Town:    


Clothing & Apparel (Choose One): Baby     Toddler     Youth     Adult


Shirt Size:     Pant Size:     Shoe Size:    

Pajamas Size:     Coat Size:     Undergarment Size:    


Prioritized Wish List:

General Interests/Hobbies:

Favorite Colors/Games/Sports/Teams/Music/TV or Movie Characters:

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Hope for the Holidays Form

If you prefer to download the form and fax it to UWRC at 845-358-8250 then please click on the link below:

PDF Form