Shop with a Cop Application

The Auburn Police Department welcomes the opportunity to work with today's youth, particularly underprivileged children who may not have the same opportunities as others their age. Shop with a Cop is one of the ways we reach out to these children and their families.

Through Shop with a Cop, children in need are able to purchase gifts for Christmas, including one needed item for themselves (such as coat, hat, clothing), as well as small gifts for other family members.

The Auburn Police Departments strives to make the day an engaging and exciting one, starting off by picking children up in one of our police vehicles and taking them (along with a parent or guardian) to Wal-Mart to select items. We generally end the excursion with a meal at a local restaurant.

The deadline for applications is December 1, 2011.
Letters of approval will be mailed to the address listed on this application.

If you prefer to download and print the Shop with a Cop form instead, click here (PDF) and return it to the address on the form.

Rules and Guidelines

Eligibility:

• Any child age 15 and under on the shopping day is eligible to apply.
• The child must be present on the shopping day in order to shop.
• Eligible children must reside full time within the city of Auburn, IN and not live with a custodial parent outside the city of Auburn IN. 
• Children must be accompanied by a parent or guardian on the shopping day.

Applications Requirements:

• Your application must be filled out completely and include a valid telephone number.
• You must enclose a copy of a current utility bill to show proof of residency in Auburn, IN.

How it Works:

• Children and parents/guardians are picked up and returned home in a marked Auburn Police Department vehicle.
• During the shopping trip, children are accompanied by a representative of the Auburn Police Department (generally a uniformed Auburn Police Officer) and given an amount of money to spend.
• Children are encouraged to buy a needed item for themselves, such as a coat, hat, gloves or sweatshirts/sweaters, for example.
• Children are generally also able to buy a small gift for other family members.
• The parent or a guardian of the child is also be accompanied by a representative of the Auburn Police Department to shop so their child(ren) will have a gift to open Christmas morning. (One gift is purchased for each child.)
• If funds allow, some parents are also able to shop for some food items.

Application

Children

Child's name *

Age *

Grade in school *

 

Child's name

Age

Grade in school

 

Child's name

Age

Grade in school

 

Child's name

Age

Grade in school

 

Responsible Party

Name of Responsible Party *

Relationship to Child: (select one) *

 Parent

 Guardian

Street address *

Apt:

City *

State *

Zip code *

Telephone number *

Best time to call

 

Household Information

Total Annual Household Income *

 $0 to $9,999

 $10,000 to $14,999

 $15,000 to $19,999

 $20,000 to $24,999

 $25,000 to $29,999

 $30,000 to $34,999

 $35,000 to $39,999

 Over $40,000

Number of people living at this address *

Are you presently working? *

 Yes

 No

If no, please list the reason for not working:

If yes, list employer and a company address:

Have you applied for assistance from any other organization? *

 Yes

 No

If so, list the name of that organization:

 

Upload utility bill

You must provide a copy of a current utility bill to show proof of residency in Auburn, IN. If you are unable to scan and upload a copy below, you may mail a copy to: Auburn Police Department, Shop With A Cop Program, 210 S Cedar St., PO Box 506, Auburn, IN 46706.

Please upload a copy of a current utility bill. The image file size must be less than 10mb.

 

ELECTRONIC SIGNATURE

Your typed name represents your signature for the purpose of authenticating this record. By completion of this application and your signature on this application, you give the Auburn Police Department the right to make inquires with other organizations about assistance you are receiving. Your signature also gives the Auburn Police Department permission to publish pictures taken during this event.

Enter your first and last name: *

Date *

 

Captcha: *

Enter the letters and numbers shown in the image

 

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