[Dallas County, IA] Benevolent Nomination Form

Dallas County, Iowa Sheriff's Benevolent Holiday Event Nomination Form

Shop With a Cop - provided to children from 6 to 12 years old residing in Dallas County, Iowa. This program provides positive interaction with an officer for low income children.Sign up deadline is November 26th or when the list is full, whichever comes first.
Food Baskets: provided to low income families residing in Dallas County Iowa struggling to provide for their family. The deadline for submission is December 9th or when the list is full, whichever comes first.

Today's Date

Does the family live in Dallas County, Iowa?

STOP! We're sorry but these programs are only available to residents within Dallas County Iowa. Please check with your local Sheriff's Office to see if comparable programs are offered in your area.

Has the child participated in the Dallas County, Iowa Shop with a Cop within the last 2 years? Children who have not participated within the last 2 years are prioritized, however answering yes will not automatically disqualify nominee.

Applying for

Full Name of Child #1

Gender of Child #1

Age of Child #1

Full Name of Child #2

Gender of Child #2

Age of Child #2

Full Name of Child #3

Gender of Child #3

Age of Child #3

Full Name of Child #4

Gender of Child #4

Age of Child #4

If Space is Not Available My First Choice is

City in Which the Family Resides:

First Name of Family Head of Household

Last Name of Family Head of Household

Family Phone Number

Does Head of Household Speak English?

Primary Language Spoken? (an interpreter may be used if accepted to program)

Submitter's First and Last Name

Submitter's Email Address

Did This Family Receive Help From Us Last Year? (answering yes will not automatically disqualify nominee)

Is The Family Receiving Help From Any Other Organization This Christmas Season?

If Yes From Whom?

Any Special Circumstances We Should Know of?

Describe Why You Believe this Family Would Benefit from this Program.