Cornelius Christmas
Family Form - 2017

Dear Special Kids Family,

Please continue to scroll and fill out each question until you reach the bottom of the application. In the family information portion, to best serve each of our families, we ask if you list whether each member in the household has a special need or not including parents, extended family, and children.

If you have any questions or concerns regarding your application, please see one of the Family Resources Staff. We pray you are abundantly blessed as this Christmas season approaches.

We look forward to serving you this year!

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* 1. Please enter applicant contact info below:

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Would you share with your sponsor a little about your current needs?

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* 3. Do you have any household needs? (For example, if you need bed sheets, please tell us the size and color preferred, i.e. "Blue sheets, Queen size". If you need curtains, please tell us the preferred color and size needed, i.e. "White curtains, 38"X72" window", etc.)

Question Title

* 4. Adult 1

Name

Male/Female

Relationship to applicant

Shirt Size:

Pant Size: (width/length)

Shoe size (only list one size) & type needed (i.e. tennis shoe, dress shoe, house shoe)

Does this family member have any needs to consider when purchasing gifts?

Favorite colors:

Greatest need:

Greatest want:

Other: (list anything else that would be helpful information in purchasing gifts)

Question Title

* 5. Adult 2

Name

Male/Female

Relationship to applicant

Shirt Size:

Pant Size: (width/length)

Shoe size (only list one size) & type needed (i.e. tennis shoe, dress shoe, house shoe)

Does this family member have any needs to consider when purchasing gifts?

Favorite colors:

Greatest need:

Greatest want:

Other: (list anything else that would be helpful information in purchasing gifts)

Question Title

* 6. Child 1

Name

Age (please no one over 18)

Male/Female

Relationship to applicant

Shirt Size:

Pant Size: (width/length)

Shoe size (only list one size) & type needed (i.e. tennis shoe, dress shoe, house shoe)

Are there any special needs that should be considered while purchasing gifts?

Favorite colors:

Greatest need:

Greatest want: (please list a few play items)

Other: (list anything else that would be helpful information in purchasing gifts:

Question Title

* 7. Child 2

Name

Age (please no one over 18)

Male/Female

Relationship to applicant

Shirt Size:

Pant Size: (width/length)

Shoe size (only list one size) & type needed (i.e. tennis shoe, dress shoe, house shoe)

Are there any special needs that should be considered while purchasing gifts?

Favorite colors:

Greatest need:

Greatest want: (please list a few play items)

Other: (list anything else that would be helpful information in purchasing gifts:

Question Title

* 8. Child 3

Name

Age (please no one over 18)

Male/Female

Relationship to applicant

Shirt Size:

Pant Size: (width/length)

Shoe size (only list one size) & type needed (i.e. tennis shoe, dress shoe, house shoe)

Are there any special needs that should be considered while purchasing gifts?

Favorite colors:

Greatest need:

Greatest want: (please list a few play items)

Other: (list anything else that would be helpful information in purchasing gifts:

Question Title

* 9. Child 4

Name

Age (please no one over 18)

Male/Female

Relationship to applicant

Shirt Size:

Pant Size: (width/length)

Shoe size (only list one size) & type needed (i.e. tennis shoe, dress shoe, house shoe)

Are there any special needs that should be considered while purchasing gifts?

Favorite colors:

Greatest need:

Greatest want: (please list a few play items)

Other: (list anything else that would be helpful information in purchasing gifts:

Question Title

* 10. Child 5

Name

Age (please no one over 18)

Male/Female

Relationship to applicant

Shirt Size:

Pant Size: (width/length)

Shoe size (only list one size) & type needed (i.e. tennis shoe, dress shoe, house shoe)

Are there any special needs that should be considered while purchasing gifts?

Favorite colors:

Greatest need:

Greatest want: (please list a few play items)

Other: (list anything else that would be helpful information in purchasing gifts:

Question Title

* 11. Child 6 or Other Adult

Name

Age

Male/Female

Relationship to applicant

Shirt Size:

Pant Size: (width/length)

Shoe size (only list one size) & type needed (i.e. tennis shoe, dress shoe, house shoe)

Are there any special needs that should be considered while purchasing gifts?

Favorite colors:

Greatest need:

Greatest want: (please list a few play items)

Other: (list anything else that would be helpful information in purchasing gifts:

Question Title

* 12. Are there any additional people living in the home?

If yes, please list their name(s) and relationship to applicant.

ATTENTION:
Signing this form does not guarantee that services will be provided for you and your family.

If you are in need of assistance with this form, please contact Sydne' in Family Resources at 615-809-2632.

I, the undersigned, do hereby consent and agree to the release of my personal information and that of my immediate family to non-profit service organizations in Rutherford County exclusively for the purpose of offering assistance to my family for Christmas. Information gathered will be contained within a secure online database and will be used for no other purpose.

I, the undersigned, accept that our family will receive the gifts at our own risk. We will not hold Special Kids, Inc., their employees, volunteers or sponsors liable for any injuries or harm. I ensure that the undersigned is the parent or legal guardian of the participating child/children.

I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.

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* 1. Please enter applicant contact info below:

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* 2. Would you share with your sponsor a little about your current needs?

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* 3. Do you have any household needs? (For example, if you need bed sheets, please tell us the size and color preferred, i.e. "Blue sheets, Queen size". If you need curtains, please tell us the preferred color and size needed, i.e. "White curtains, 38"X72" window", etc.)

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* 4. Adult 1

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* 5. Adult 2

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* 6. Child 1

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* 7. Child 2

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* 8. Child 3

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* 9. Child 4

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* 10. Child 5

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* 11. Child 6 or Other Adult

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* 12. Are there any additional people living in the home?

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* 13. Please sign below: