Adopt-A-Family 2020 Step 1 of 8 12% Still Waters Referring Employee InformationBelow is dedicated to the person MAKING the "Adopt-A-Family" referral. Note: We are ONLY taking referrals from Still Waters Employees this year.Date of Referral Date Format: MM slash DD slash YYYY Still Waters Employee - Name* First Last Still Waters Employee - Email Still Waters Employee - PhonePlease give the best phone number that you can be reached for questions concerning this referral.Still Waters Employee - DescriptionPlease select which best describes your role at Still Waters. Counselor Intake Worker Team Leader Contractor Intern Director Administrative Staff Manager Other 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.Family Unit - Total Number of Children Being ReferredAdditional 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 (2) designated gift pick-up days. Please select the preferred option. Please remind those who pick-up to abide by covid-19 protocol and to also bring a verification ID.Family Unit - Gift Pick-Up AgreementGift pick-up will be at Revifify Church located at: 4350 Wheeler R. Augusta, GA 30907 Family Representative Pick-up Sat. Dec. 12, 2020 - 11:00 AM to 4:00 PM Family Representative Pick-up Sun. Dec. 13, 2020 - 11:00 AM to 1:00 PM Need gifts delivered to address listed below. Still Waters Employee who is referring this family unit, agrees to pick-up and deliver the gifts. Person authorized to pick-up giftsPlease list all people who authorized to pick-up the gifts. All authorized must present valid identification.Deliver to Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Special Pick-Up Notes Child 1Child 1 - Name First Last Child 1 - AgePlease indicate months or years old below.Child 1 - Months or Years Months Years Child 1 - Gender Male Female Transgender (Female to Male) Transgender (Male to Famale) Child 1 - RaceThis section is optional, however it helps in selcting gifts such as hair products.Child 1 - 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 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 ColorsChild 1 - Urgent NeedsList only if child has a urgent needs. Example: Child really needs tennis shoes for school.Child 1 - Needs/Wants Clothing/ShoesSkip to next child if "No" is selected, fill out sizes if "Yes" or "Either/Or" is selected. IMPORTANT! Please indicate sizes and check the appropriate box under so that we assure the child gets things that fit! Yes No Either/Or Child 1 - Shoe Size AChild 1 - Shoe Size B Infant Child Junior Adult Child 1 - Shirt Size AChild 1 - Shirt Size B Infant Child Junior Adult Child 1 - Pants Size AChild 1 - Pants Size B Infant Child Junior Adult Child 1 - Coat Size AChild 1 - Coat Size B Infant Child Junior Adult Child 2Child 2 - Name First Last Child 2 - AgePlease indicate months or years old below.Child 2 - Months or Years Months Years Child 2 - Gender Male Female Transgender (Female to Male) Transgender (Male to Famale) 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 ColorsChild 2 - Urgent NeedsList only if child has a urgent needs. Example: Child really needs tennis shoes for school.Child 2 - Needs/Wants Clothing/ShoesSkip to next child if "No" is selected, fill out sizes if "Yes" or "Either/Or" is selected. IMPORTANT! Please indicate sizes and check the appropriate box under so that we assure the child gets things that fit! Yes No Either/Or Child 2 - Shoe Size AChild 2 - Shoe Size B Infant Child Junior Adult Child 2 - Shirt Size AChild 2 - Shirt Size B Infant Child Junior Adult Child 2 - Pants Size AChild 2 - Pants Size B Infant Child Junior Adult Child 2 - Coat Size AChild 2 - Coat Size B Infant Child Junior Adult Child 3Child 3 - Name First Last Child 3 - AgePlease indicate months or years old below.Child 3 - Months or Years Months Years Child 3 - Gender Male Female Transgender (Female to Male) Transgender (Male to Famale) 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 3 - Favorite ColorsChild 3 - Urgent NeedsList only if child has a urgent needs. Example: Child really needs tennis shoes for school.Child 3 - Needs/Wants Clothing/ShoesSkip to next child if "No" is selected, fill out sizes if "Yes" or "Either/Or" is selected. IMPORTANT! Please indicate sizes and check the appropriate box under so that we assure the child gets things that fit! Yes No Either/Or Child 3 - Shoe Size AChild 3 - Shoe Size B Infant Child Junior Adult Child 3 - Shirt Size AChild 3 - Shirt Size B Infant Child Junior Adult Child 3 - Pants Size AChild 3 - Pants Size B Infant Child Junior Adult Child 3 - Coat Size AChild 3 - Coat Size B Infant Child Junior Adult Child 4Child 4 - Name First Last Child 4 - AgePlease indicate months or years old below.Child 4 - Months or Years Months Years Child 4 - Gender Male Female Transgender (Female to Male) Transgender (Male to Famale) 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 ColorsChild 4 - Urgent NeedsList only if child has a urgent needs. Example: Child really needs tennis shoes for school.Child 4 - Needs/Wants Clothing/ShoesSkip to next child if "No" is selected, fill out sizes if "Yes" or "Either/Or" is selected. IMPORTANT! Please indicate sizes and check the appropriate box under so that we assure the child gets things that fit! Yes No Either/Or Child 4 - Shoe Size AChild 4 - Shoe Size B Infant Child Junior Adult Child 4 - Shirt Size AChild 4 - Shirt Size B Infant Child Junior Adult Child 4 - Pants Size AChild 4 - Pants Size B Infant Child Junior Adult Child 4 - Coat Size AChild 4 - Coat Size B Infant Child Junior Adult Child 5Child 5 - Name First Last Child 5 - AgePlease indicate months or years old below.Child 5 - Months or Years Months Years Child 5 - Gender Male Female Transgender (Female to Male) Transgender (Male to Famale) 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 ColorsChild 5 - Urgent NeedsList only if child has a urgent needs. Example: Child really needs tennis shoes for school.Child 5 - Needs/Wants Clothing/ShoesSkip to next child if "No" is selected, fill out sizes if "Yes" or "Either/Or" is selected. IMPORTANT! Please indicate sizes and check the appropriate box under so that we assure the child gets things that fit! Yes No Either/Or Child 5 - Shoe Size AChild 5 - Shoe Size B Infant Child Junior Adult Child 5 - Shirt Size AChild 5 - Shirt Size B Infant Child Junior Adult Child 5 - Pants Size AChild 5 - Pants Size B Infant Child Junior Adult Child 5 - Coat Size AChild 5 - Coat Size B Infant Child Junior Adult Child 6Child 6 - Name First Last Child 6 - AgePlease indicate months or years old below.Child 6 - Months or Years Months Years Child 6 - Gender Male Female Transgender (Female to Male) Transgender (Male to Famale) 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 ColorsChild 6 - Urgent NeedsList only if child has a urgent needs. Example: Child really needs tennis shoes for school.Child 6 - Needs/Wants Clothing/ShoesSkip to next child if "No" is selected, fill out sizes if "Yes" or "Either/Or" is selected. IMPORTANT! Please indicate sizes and check the appropriate box under so that we assure the child gets things that fit! Yes No Either/Or Child 6 - Shoe Size AChild 6 - Shoe Size B Infant Child Junior Adult Child 6 - Shirt Size AChild 6 - Shirt Size B Infant Child Junior Adult Child 6 - Pants Size AChild 6 - Pants Size B Infant Child Junior Adult Child 6 - Coat Size AChild 6 - Coat Size B Infant Child Junior Adult
