Shop with a Cop

2023 Shop With a Cop Application

Only Hendricks County, IN residents are eligible for the program. Proof of residency (utility company or credit card bill, doctor or hospital bill, bank statement or bank transaction receipt, pre-printed pay stub, dated within 60 days of the application) must be provided.

All fields are required. A telephone number must accompany this form. No one 13 years of age or over is eligible to participate. On the shopping day, your child will need to be present in order to shop.

Information about children participating(Required)

Child's Name

Age

Grade

To add additional, click the "plus" icon at the end of the row

Name of Responsible Party:(Required)

First Last

Relationship to Child(Required)

Parent

Guardian

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Telephone Number(Required)

Best Time to Call

:

Total Annual Household Income:(Required)

Number of Persons in the Household(Required)

Have you recently been laid off?(Required)

Yes

No

Name of School

Have you applied for assistance from any other organizations?(Required)

Yes

No

If so, name of organization(Required)

Proof of Residency(Required)

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, docx, Max. file size: 50 MB.

By completing and your signature on this application, you give the F.O.P. the right to make inquiries with other organizations about assistance you are receiving.

Signature(Required)

Date(Required)

Applications must be filled out by December 1, 2023

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