Adopt-A-Family 2024 "*" indicates required fields Step 1 of 8 12% Date of Referral MM slash DD slash YYYY Submitter's InformationPerson submitting (making) this Adopt-A-Family referral. Please list all information requested.Submitter's - Name* First Last Submitter's - Email Submitter's - PhonePlease give the best phone number that you can be reached for questions concerning this referral. Family Unit InformationThis section is dedicated to determining who is the head of household (responsible party) for this referral and to determine key contacts for questions.Family Unit - Parent or Guardian Name First Last Family Unit - PhonePlease list best reach phone number here.IMPORTANT! Total Number of Children Being ReferredIMPORTANT! Please list the number of people receiving gifts this year. Do not include the parent or guardian.Additional forms submitted?This online form accommodates inputing 6 children. If there are more than 6 children to submit you will need to do an additional form. Please indicate if you are submitting an additional form. Yes No Family Unit - ConsentPlease get a verbal consent from the Family Unit Parent or Guardian. By clicking this box the person referring is attesting to the verbal agreement. I agree to participate in the Adopt-A-Family ProgramSignatureI attest that the Family Unit - Parent or Guardian Listed above gave verbal permission to participate in the Adopt-A-Family Program.Adopt-A-Family Gift Pick-Up AgreementThis year, there will be (1) designated gift pick-up day. Please remind those who pick-up to abide by covid-19 protocol and to also bring a verification ID.Family Unit - Gift Pick-Up AgreementPlease give this pick-up address to the referred family. GIFT PICK-UP LOCATION: Revifify Church 4350 Wheeler Rd. Augusta, GA 30907 PICK-UP DATE: DEC. 7, 2024 PICK-UP TIME: 9:30 AM to 1:30 PM IMPORTANT! The church will no longer be delivering gifts. If you select delivery YOU must agree to deliver or make an agreement with another Still Waters employee to deliver. Family Representative Pick-up Still Waters Employee (who is referring this family), agrees to pick-up and deliver the gifts. IMPORTANT! The church wil no longer be delivering. Deliver to AddressIf you plan on delivering the gifts, please list where they should go for your reference. Street Address City State / Province / Region ZIP / Postal Code Person authorized to pick-up giftsPlease list all people who authorized to pick-up the gifts. All authorized must present valid identification.Special Pick-Up Notes Child 1Child 1 - Name First Last Child 1 - AgePlease indicate months or years old.Child 1 - Months or Years Months Years Child 1 - Gender Male Female Transgender (Identifies as Male) Transgender (Identifies as Female) Child 1 - RaceThis section is optional, however, it helps in selecting certain gifts such as hair products. Child 1 - Important Health InformationPlease list here any allergies or health issues that need to be considered while buying gifts. Example: No flashing light toys due to seizures, child is allergic to the stuffing in plush toys, peanut allergies etc.Child 1 - Interests and PreferencesList here ideas for gifts. Please be specific. Example: if video games wanted, indicate the game console. Be as specific as possible. Other examples: Likes Hello Kitty, wants the Hello Kitty Lip Stick Kit or Child loves basketball and wants a basketball hoop. Note: There are no guarantees the child will receive these items but it is helpful information for gift buyers.Child 1 - Favorite Colors Child 1 - Urgent NeedsList only if child has a urgent needs. Example: Child really needs tennis shoes for school.Child 1 - Shoe Size A Child 1 - Shoe Size B Infant Toddler Youth Adult Child 1 - Shirt Size A Child 1 - Shirt Size B Infant Child Junior Adult Child 1 - Pants Size A Child 1 - Pants Size B Infant Child Junior Adult Child 1 - Coat Size A Child 1 - Coat Size B Infant Child Junior Adult Child 2Child 2 - Name First Last Child 2 - AgePlease indicate months or years old.Child 2 - Months or Years Months Years Child 2 - Gender Male Female Transgender (Identifies as Male) Transgender (Identifies as Female) Child 2 - RaceThis section is optional, however it helps in selcting gifts such as hair products. Child 2 - Important Health InformationPlease list here in allergies or health issues that would concern gift options. Example: No flashing light toys due to seizures, child is allergic to the stuffing in plush toys, peanut allergies etc.Child 2 - Interests and PreferencesList here ideas for gifts. Please be specific, example if video games wanted, indicate the game console. Be as specific as possible. Other examples: Likes Hello Kitty, wants the Hello Kitty Lip Stick Kit or Child loves basketball and wants a basketball hoop. Note: There are no guarantees the child will receive these items but it is helpful information for gift buyers.Child 2 - Favorite Colors Child 2 - Urgent NeedsList only if child has a urgent needs. Example: Child really needs tennis shoes for school.Child 2 - Shoe Size A Child 2 - Shoe Size B Infant Toddler Youth Adult Child 2 - Shirt Size A Child 2 - Shirt Size B Infant Child Junior Adult Child 2 - Pants Size A Child 2 - Pants Size B Infant Child Junior Adult Child 2 - Coat Size A Child 2 - Coat Size B Infant Child Junior Adult Child 3Child 3 - Name First Last Child 3 - AgePlease indicate months or years old.Child 3 - Months or Years Months Years Child 3 - Gender Male Female Transgender (Identifies as Male) Transgender (Identifies as Female) Child 3 - RaceThis section is optional, however it helps in selcting gifts such as hair products. Child 3 - Important Health InformationPlease list here in allergies or health issues that would concern gift options. Example: No flashing light toys due to seizures, child is allergic to the stuffing in plush toys, peanut allergies etc.Child - Interests and PreferencesList here ideas for gifts. Please be specific, example if video games wanted, indicate the game console. Be as specific as possible. Other examples: Likes Hello Kitty, wants the Hello Kitty Lip Stick Kit or Child loves basketball and wants a basketball hoop. Note: There are no guarantees the child will receive these items but it is helpful information for gift buyers.Child 3 - Favorite Colors Child 3 - Urgent NeedsList only if child has a urgent needs. Example: Child really needs tennis shoes for school.Child 3 - Shoe Size A Child 3 - Shoe Size B Infant Toddler Youth Adult Child 3 - Shirt Size A Child 3 - Shirt Size B Infant Child Junior Adult Child 3 - Pants Size A Child 3 - Pants Size B Infant Child Junior Adult Child 3 - Coat Size A Child 3 - Coat Size B Infant Child Junior Adult Child 4Child 4 - Name First Last Child 4 - AgePlease indicate months or years old.Child 4 - Months or Years Months Years Child 4 - Gender Male Female Transgender (Identifies as Males) Transgender (Identifies as Female) Child 4 - RaceThis section is optional, however it helps in selcting gifts such as hair products. Child 4 - Important Health InformationPlease list here in allergies or health issues that would concern gift options. Example: No flashing light toys due to seizures, child is allergic to the stuffing in plush toys, peanut allergies etc.Child 4 - Interests and PreferencesList here ideas for gifts. Please be specific, example if video games wanted, indicate the game console. Be as specific as possible. Other examples: Likes Hello Kitty, wants the Hello Kitty Lip Stick Kit or Child loves basketball and wants a basketball hoop. Note: There are no guarantees the child will receive these items but it is helpful information for gift buyers.Child 4 - Favorite Colors Child 4 - Urgent NeedsList only if child has a urgent needs. Example: Child really needs tennis shoes for school.Child 4 - Shoe Size A Child 4 - Shoe Size B Infant Toddler Youth Adult Child 4 - Shirt Size A Child 4 - Shirt Size B Infant Child Junior Adult Child 4 - Pants Size A Child 4 - Pants Size B Infant Child Junior Adult Child 4 - Coat Size A Child 4 - Coat Size B Infant Child Junior Adult Child 5Child 5 - Name First Last Child 5 - AgePlease indicate months or years old.Child 5 - Months or Years Months Years Child 5 - Gender Male Female Transgender (Identifies as Male) Transgender (Identifies as Female) Child 5 - RaceThis section is optional, however it helps in selcting gifts such as hair products. Child 5 - Important Health InformationPlease list here in allergies or health issues that would concern gift options. Example: No flashing light toys due to seizures, child is allergic to the stuffing in plush toys, peanut allergies etc.Child 5 - Interests and PreferencesList here ideas for gifts. Please be specific, example if video games wanted, indicate the game console. Be as specific as possible. Other examples: Likes Hello Kitty, wants the Hello Kitty Lip Stick Kit or Child loves basketball and wants a basketball hoop. Note: There are no guarantees the child will receive these items but it is helpful information for gift buyers.Child 5 - Favorite Colors Child 5 - Urgent NeedsList only if child has a urgent needs. Example: Child really needs tennis shoes for school.Child 5 - Shoe Size A Child 5 - Shoe Size B Infant Toddler Youth Adult Child 5 - Shirt Size A Child 5 - Shirt Size B Infant Child Junior Adult Child 5 - Pants Size A Child 5 - Pants Size B Infant Child Junior Adult Child 5 - Coat Size A Child 5 - Coat Size B Infant Child Junior Adult Child 6Child 6 - Name First Last Child 6 - AgePlease indicate months or years old.Child 6 - Months or Years Months Years Child 6 - Gender Male Female Transgender (Identifies as Male) Transgender (Identifies as Female) Child 6 - RaceThis section is optional, however it helps in selcting gifts such as hair products. Child 6 - Important Health InformationPlease list here in allergies or health issues that would concern gift options. Example: No flashing light toys due to seizures, child is allergic to the stuffing in plush toys, peanut allergies etc.Child 6 - Interests and PreferencesList here ideas for gifts. Please be specific, example if video games wanted, indicate the game console. Be as specific as possible. Other examples: Likes Hello Kitty, wants the Hello Kitty Lip Stick Kit or Child loves basketball and wants a basketball hoop. Note: There are no guarantees the child will receive these items but it is helpful information for gift buyers.Child 6 - Favorite Colors Child 6 - Urgent NeedsList only if child has a urgent needs. Example: Child really needs tennis shoes for school.Child 6 - Shoe Size A Child 6 - Shoe Size B Infant Toddler Youth Adult Child 6 - Shirt Size A Child 6 - Shirt Size B Infant Child Junior Adult Child 6 - Pants Size A Child 6 - Pants Size B Infant Child Junior Adult Child 6 - Coat Size A Child 6 - Coat Size B Infant Child Junior Adult Section Break Δ
