Name: *

First Name

Last Name

Phone: *

(###)

###

####

Alternate phone:

(###)

###

####

Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you participating in any other holiday gift programs (i.e. HM Life, Salvation Army, etc.)? Please note that you are only allowed to participate in one holiday assistance program each year. Information will be verified. *

Yes

No

Can we share your first name as well as your kids' first names with donors? *

Yes, you can disclose our first names to donors.

No, please do not disclose our first names.

Mother/Guardian Information: *

First Name

Last Name

Child #1

First Name

Last Name

Male

Female

I prefer not to specify.

Child #2

First Name

Last Name

Male

Female

Prefer not to specify.

Child #3

First Name

Last Name

Male

Female

Prefer not to specify.

Child #4

First Name

Last Name

Male

Female

Prefer not to specify

Child #5

First Name

Last Name

Male

Female

Prefer not to specify

Child #6

First Name

Last Name

Male

Female

Prefer not to specify