Broken Arrow Neighbors Appointment Request Form (Holiday)
Are you a current client of Broken Arrow Neighbors or have you requested assistance in the past?
Address *
What type of assistance are you requesting: *

Holiday Assistance

Have you registered to receive Holiday assistance from any other agency? *
I understand that if I secure services from multiple agencies/resources without disclosing that information with Broken Arrow Neighbors and we are made aware of this duplication, my future services from BAN may be in jeopardy. *
Is my file documentation updated and complete? This includes: Current ID/Birth Certificate for everyone in household, Proof of Address, Proof of all Income. *
Are you an Outreach Client? *

Children For Gift Gallery

Only List Names of Children for Gift Gallery (Newborn – 10 Years Old ONLY) << BOLD
Gender *
Maximum upload size: 134.22MB
Required documentation – for each adult in the household (including adult children that are 19 or older) we require the following documentation:

Adult in the Household

Current* proof of Broken Arrow address (current utility bill or legal/dated mail
Maximum upload size: 134.22MB
Valid Driver’s License or Photo
Maximum upload size: 134.22MB
Current* proof of income
Maximum upload size: 134.22MB
This could be a Pay stub, Award letters for any form of government assistance (including, but not limited to: Unemployment Compensation, Workman’s Compensation, Food Stamps/SNAP, Disability, Social Security, Medicaid, Medicare, Sooner Care, Heartland and TANF)**

*Date must be within 30 days of actual date
**A copy of awards/benefits letters may be obtained by contacting DHS at 1-877-653-4798

Required documentation – for each child in the household:

Child in the Household

Copy of birth certificate (or immunization record)
Maximum upload size: 134.22MB

Food Pantry Appointment times are made Monday – Thursday from 10am to 2pm daily. We are open for working clients on Monday and Thursday evenings from 5pm to 7pm. If you have any questions, please call us at 918.251.7781