EmailMe Form - Jurupa Valley Adopt a Family Program 2025

Jurupa Valley Adopt a Family Program 2025

Jurupa Valley Adopt a Family Program 2025 Application

For over 30 years, community members of Jurupa Valley and volunteers from other local areas have organized an Annual Adopt a Family program where we provide food, clothing, hygiene aids, school supplies, Christmas decorations and of course toys to the needy families of the Jurupa Communities. Each year, we join Santa Claus in delivering the items to these families over several days just prior to Christmas. Since its inception, we have supported over 900 families and brought holiday cheer to thousands of children.
2025 Program

In 2025 the Jurupa Valley Adopt a Family program will provide donations to community families that can show a verifiable need. Each family will be required to complete an application and participate in a pre-event in home screening. Applicants (or identified families) will be interviewed to ensure eligibility. Families will be notified during the second week of December of their application approval by phone or mail. Please note that due to the uncertainty of donation, children over the age of 15 not guaranteed to receive toys.

Pick-ups will likely be completed between December 19th and December 22nd. During this time Santa Claus will be making deliveries on board is sleigh joined by dozens of program participants. Children are required to be at home during the time of delivery. Additional families may be chosen for non-delivery support that will require them to pick up from a designated area during the same week.
Terms and conditions
Applicants must:

*Complete the entire application and sign it

*Be willing to participate in the pre-event screening

*Have children home during delivery

*Provide a place within their home for Santa to make contact with the children

*Not be participating in any additional programs that provide similar support

*Be willing to be photographed or have video taken of all parties for use in future marketing

*Provide proof of residency (Identification Card, Driver’s License or Utility Bill)

*Provide proof of income if requested (Payroll stubs, Previous year W-2)

Additional Information

*Deliveries are brought by fire engines using lights and sirens and other parade vehicles.

*Santa Claus will be accompanied by program volunteers

*Pictures and video may be taken during the delivery.

*Application information is not shared with anyone outside of program administrators

*Information about families will not be shared with neighbors or with the media.

*Perishable food will be provided. Families need to advise the program ahead of time if there is no way to maintain perishable products. Every effort will be made to provide alternative non-perishable food to those families.

*Special needs or allergies must be listed on the application.
I have read and agree to the Terms and Conditions above *
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The food and items provided are collected by donations from the community. The Jurupa Valley Adopt a Family cannot be held liable for bad products. It is the responsibility of the recipient families to ensure all products are in safe working condition and/or safe for consumption. *
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It is the applicant’s responsibility to ensure they are available for contact by program administrators. Reasonable attempts will be made to contact applicants; however, applicants who cannot be reached by telephone or who do not return phone calls will have their application denied. *
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Applicant’s who have been awarded assistance during the previous three years must attach an additional one page narrative describing any extenuating circumstances. In most instances families who have received assistance within three years are ineligible. *
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Applicant households must be in the City of Jurupa Valley and all participants must live with the applicant. If needed we may be able to assist you with finding a program in your area. *
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Eligibility Requirements
To apply for assistance applicant household must meet one of the following qualifications.

Income

Maximum household gross income for two person households is $24,000 per year, for three members it is $28,200 and for four person households it is $34,000. For every person above four in the household, the maximum rises by $5,800. Applicants for the program will need to present proof of income in the form of tax returns, pay stubs or government benefits statements for all adults living in the house.

Program

Anyone who qualifies for Medicaid or Medi-Cal, Temporary Assistance for Needy Families, Food Stamps, Supplemental Security Income, Low Income Home Energy Assistance Program, the Women, Infants and Children program, the National School Lunch's free lunch program or California Lifeline may apply. Proof of involvement in qualifying program may be requested.
I have read and understand Eligibility Requirements *
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The Jurupa Valley Adopt a Family Program does not discriminate against any person on the basis of race, color, national origin, disability, sex or age in admission, treatment, or participation in its

programs, services and activities. No person shall be excluded from participation in, or be denied the benefits of any service, or be subjected to discrimination because of race, color, nationality, religion, sex, age, disability.
The Jurupa Valley Adopt a Family program is a 501C3 Non-Profit and not part of any government entity.
Applicant Name *
First Last
Spouses Name
First Last
Home Address *

Street Address City State / Province / Region Postal / Zip Code
Home Phone
### - ### - ####
Cell/Other Phone
### - ### - ####
Email
Children Information
Do you have a child with special needs? *
Yes
No
How many children in the home? *
Please list children information:
Child #1 Name *
First Last
Age *
Gender *
Special Needs
Child #2 Name
First Last
Age
Gender
Special Needs
Child #3 Name
First Last
Age
Gender
Special Needs
Child #4 Name
First Last
Age
Gender
Special Needs
Child #5 Name
First Last
Age
Gender
Special Needs
Status of Home *
Two parents/guardians
Single parent/guardian
Foster Home
Number of adults in home *
Gross Household Income (combined for all adults in home) *
$ Dollars . Cents
Income Above Is: *
Do you meet the eligibility requirements listed above? *
Yes
No
Have you received assistance from this program in the last three years? *
Yes
No
If you answered yes to the previous question, please provide us with information about why your situation has changed from previous years.
Residency
Have you been a resident of the State of California for the two years preceding the date on this application? *
Yes
No
Special Holiday Needs
Do you have special holiday needs? (i.e. gluten free/casein free foods, allergen free foods) - what are the specific allergies?
Supplements (please list), if for diapers - what size?
Pick-ups will be made between December 19th and 22nd. Are there specific date(s) within that range that the children will not be home?
I certify that the information on this form is true and complete to the best of my knowledge and I agree with all terms and conditions.
Signature *
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Date *
MM / DD / YYYY
Date Time
MM / DD / YYYY
Date Time
MM / DD / YYYY