Christmas Adopt a Family - Family Wishlist

This is the first time my family has participated in the United Way's Christmas Adopt a Family Program

This box must be checked in order to proceed with this application. Repeat families will not be accepted.

Today's Date:

Referred By:

Family Information

Family Contact Name

Contact Method

Family Contact Phone Number

Family Contact Email

Alternate Contact Name

Contact Method

Alternate Contact Phone Number

Alternate Contact Email

Street Name

Number of House or Building or Apartment

City/Town

ZIP/Postal Code

Address

Address 2

City/Town

ZIP/Postal Code

Family Members

Children in Family

Class of Hardship

Family Story (please do not include names for privacy)