Christmas with a First Responder

This form is for participating schools to report how they used the funds provided through the Christmas with a First Responder program. Each participating school received $1,000 in Walmart gift cards to purchase Christmas presents for children served by their school. These funds must be used solely for that purpose.

Please accurately report the students assisted, items purchased, amount spent, and any remaining gift card balances. Copies of receipts must be uploaded to document all reported spending.

The completed form and receipts must be submitted by Friday, January 15, 2027. Any gift cards with remaining balances must also be returned to the Pikeville Police Department by that date.

School Name

Title

Name

School Address

Phone Number

Email Address

Number of Students

Student’s Name #1

Student’s Name #2

Student’s Name #3

Student’s Name #4

Student’s Name #5

Student’s Name #6

Student’s Name #7

Student’s Name #8

Student’s Name #9

Student’s Name #10

Student’s Age #1

Student’s Age #2

Student’s Age #3

Student’s Age #4

Student’s Age #5

Student’s Age #6

Student’s Age #7

Student’s Age #8

Student’s Age #9

Student’s Age #10

Student’s Grade #1

Student’s Grade #2

Student’s Grade #3

Student’s Grade #4

Student’s Grade #5

Student’s Grade #6

Student’s Grade #7

Student’s Grade #8

Student’s Grade #9

Student’s Grade #10

Total Spent on Student #1

Total Spent on Student #2

Total Spent on Student #3

Total Spent on Student #4

Total Spent on Student #5

Total Spent on Student #6

Total Spent on Student #7

Total Spent on Student #8

Total Spent on Student #9

Total Spent on Student #10

Items Purchased for Student #1

Add as many as necessary

Items Purchased for Student #2

Add as many as necessary

Items Purchased for Student #3

Add as many as necessary

Items Purchased for Student #4

Add as many as necessary

Items Purchased for Student #5

Add as many as necessary

Items Purchased for Student #6

Add as many as necessary

Items Purchased for Student #7

Add as many as necessary

Items Purchased for Student #8

Add as many as necessary

Items Purchased for Student #9

Add as many as necessary

Items Purchased for Student #10

Add as many as necessary

Last 4 Digits of Gift Card #1

Last 4 Digits of Gift Card #2

Total Remaining Balance of Gift Card #1

Total Remaining Balance of Gift Card #2

Combined Remaining Balance

I certify that all information provided, including receipts, amounts spent per student, remaining balances, and student names, grades, and ages, is accurate and complete. I confirm that I am authorized to share this student information and that the funds were used for their intended purpose. I understand Pikeville Police Department will use this information only for reconciliation, reporting, and audit purposes.

I agree

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