Still Standing Recipient Information

"*" indicates required fields

Step 1 of 8

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Referring Employee Information

Below is dedicated to the person MAKING the "Still Standing" referral.

Date of Referral

MM slash DD slash YYYY

Still Waters Employee - Name*

First Last

Still Waters Employee - Email

Still Waters Employee - Phone

Please give the best phone number that you can be reached for questions concerning this referral.

Family Unit Information

This 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 - Phone

Please list best reach phone number here.

Family Unit - Total Number of Children Being Referred

IMPORTANT! Please list the number of people receiving gifts this year. Do not include the parent or guardian.

Additional forms submitted?

Yes

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.

Family Unit - Consent

I agree to participate in the Adopt-A-Family Program

Please get a verbal consent from the Family Unit Parent or Guardian. By clicking this box the person referring is attesting to the verbal agreement.

Signature

I attest that the Family Unit - Parent or Guardian Listed above gave verbal permission to participate in the Adopt-A-Family Program.

If delivery involved …

Family or Individual will pick-up items

Family Representative Pick-up Sat. Dec. 11, 2021 - 11:00 AM to 4:00 PM

Gifts need delivered to address listed below.

Still Waters Employee (who is referring this family), agrees to pick-up and deliver.

Gift pick-up will be at Revifify Church located at: 4350 Wheeler R. Augusta, GA 30907 (Please give this pick-up address to the referred family)

Deliver to Address

Street Address City State / Province / Region ZIP / Postal Code

Person authorized to pick-up gifts

Please list all people who authorized to pick-up the gifts. All authorized must present valid identification.

Special Pick-Up Notes

Child 1

Child 1 - Name

First Last

Child 1 - Age

Please indicate months or years old.

Child 1 - Months or Years

Months

Years

Child 1 - Gender

Male

Female

Transgender (Female to Male)

Transgender (Male to Famale)

Child 1 - Race

This section is optional, however, it helps in selecting certain gifts such as hair products.

Child 1 - Important Health Information

Please 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 Preferences

List 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 Needs

List only if child has a urgent needs. Example: Child really needs tennis shoes for school.

Child 1 - Needs/Wants Clothing/Shoes

Yes

Either/Or

Skip 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!

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 2

Child 2 - Name

First Last

Child 2 - Age

Please indicate months or years old.

Child 2 - Months or Years

Months

Years

Child 2 - Gender

Male

Female

Transgender (Female to Male)

Transgender (Male to Famale)

Child 2 - Race

This section is optional, however it helps in selcting gifts such as hair products.

Child 2 - Important Health Information

Please 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 Preferences

List 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 Needs

List only if child has a urgent needs. Example: Child really needs tennis shoes for school.

Child 2 - Needs/Wants Clothing/Shoes

Yes

Either/Or

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 3

Child 3 - Name

First Last

Child 3 - Age

Please indicate months or years old.

Child 3 - Months or Years

Months

Years

Child 3 - Gender

Male

Female

Transgender (Female to Male)

Transgender (Male to Famale)

Child 3 - Race

This section is optional, however it helps in selcting gifts such as hair products.

Child 3 - Important Health Information

Please 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 Colors

Child 3 - Urgent Needs

List only if child has a urgent needs. Example: Child really needs tennis shoes for school.

Child 3 - Needs/Wants Clothing/Shoes

Yes

Either/Or

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 4

Child 4 - Name

First Last

Child 4 - Age

Please indicate months or years old.

Child 4 - Months or Years

Months

Years

Child 4 - Gender

Male

Female

Transgender (Female to Male)

Transgender (Male to Famale)

Child 4 - Race

This section is optional, however it helps in selcting gifts such as hair products.

Child 4 - Important Health Information

Please 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 Preferences

Child 4 - Favorite Colors

Child 4 - Urgent Needs

List only if child has a urgent needs. Example: Child really needs tennis shoes for school.

Child 4 - Needs/Wants Clothing/Shoes

Yes

Either/Or

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 5

Child 5 - Name

First Last

Child 5 - Age

Please indicate months or years old.

Child 5 - Months or Years

Months

Years

Child 5 - Gender

Male

Female

Transgender (Female to Male)

Transgender (Male to Famale)

Child 5 - Race

This section is optional, however it helps in selcting gifts such as hair products.

Child 5 - Important Health Information

Please 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 Preferences

Child 5 - Favorite Colors

Child 5 - Urgent Needs

List only if child has a urgent needs. Example: Child really needs tennis shoes for school.

Child 5 - Needs/Wants Clothing/Shoes

Yes

Either/Or

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 6

Child 6 - Name

First Last

Child 6 - Age

Please indicate months or years old.

Child 6 - Months or Years

Months

Years

Child 6 - Gender

Male

Female

Transgender (Female to Male)

Transgender (Male to Famale)

Child 6 - Race

This section is optional, however it helps in selcting gifts such as hair products.

Child 6 - Important Health Information

Please 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 Preferences

Child 6 - Favorite Colors

Child 6 - Urgent Needs

List only if child has a urgent needs. Example: Child really needs tennis shoes for school.

Child 6 - Needs/Wants Clothing/Shoes

Yes

Either/Or

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