Maricopa Police Department Shop with a Cop Submission Form

PERSON COMPLETING FORM

Full Name * (required)

Email Address * (required)

Phone Number * (required)

Relationship to Child

CHILD INFORMATION

Full Name * (required)

Date of Birth * (required)Date of Birth * (required)

Open the calendar popup.

School Child Attends * (required)

Has the Child participated in Shop with a Cop previously? * (required)

Does the child have any special needs or require additional support? * (required)

LEGAL GUARDIAN INFORMATION

Full Name * (required)

Address * (required)

Home Phone Number * (required)

Cellular Phone Number * (required)

Relationship to Child * (required)

SIBLING INFORMATION

Name and Age of 1st Sibling

Name and Age of 2nd Sibling

Name and Age of 3rd Sibling

If more than 3 siblings, include their names and ages here

REASON FOR REFERRAL

Please provide as much detail as possible. We ask that you include specific details about the family's financial circumstance and any unique challenges the child is facing. This could include recent hardships, family dynamics, or other factors that impact the child's daily life. General statements such as "financial hardship" are not sufficient for us to understand the child's situation. This information is confidential and will only be shared with the MPD Shop with a Cop selection committee.

It helps us select children who would greatly benefit from this opportunity. Our goal is to ensure that this program creates a positive and meaningful experience for children who may not otherwise have a chance to enjoy the holidays in this way.

Write your response here: * (required)