Project Bethlehem Recipient Form PreparerPreparer's Name(Required) First Last Email(Required) Phone(Required)Date(Required) MM slash DD slash YYYY Is your referral source a school or agency?(Required) Agency School Other Referral Source (Agencies)(Required)Please select one:Arbour CounselingLazarus House, Capernaum Place (18 units)Dept. of Children & FamiliesDept. of Mental HealthFamily ContinuityFamily Services of the Merrimack ValleyFamilies & Youth Initiative (PATCH)GLCAC (Community & Family Support Center and Head Start)Greater Lawrence Family Health CenterJeanne Geiger Crisis Center Family SafetyChildren’s Friend & Family ServicesJRIKid-Start, IncLazarus House, Family Shelter (5 families)MSPCC/Healthy FamiliesNotre Dame Educational CenterProfessional Center for Child DevelopmentCommunity Day Care/Teen Parent ProgramPeabody Resident Services/Saunders School ApartmentsSi Se PuedeSpark*LESupportive CareThe Mentor Network/South Bay/Early Intervention & Mental HealthUtec, Inc.Other:Referral Source (Schools)(Required)Please select one:Abbott Lawrence Academy (HS)Arlington Elementary (Community Day)Arlington MiddleBreenBruce SchoolCDCPS Prospect -ELC/US/LSCDCPS Webster-ELC/LS/USCDCPS Gateway – ELC /USENLACE (HS)Frost ElementaryFrost MiddleGuilmette ElementaryGuilmette MiddleHigh School Learning CenterHennessey SchoolInternational High SchoolLawlorLawrence Family Development Charter SchoolLawrence Family Public AcademyLeahyLower School, 9th GradeLower School, 10th GradeOliver PartnershipParthum ElementaryParthum MiddleRISE (HS)Rollins Early Childhood CenterSES – School for Exceptional StudiesSES at Bruce AnnexSouth Lawrence EastSpark AcademyTarboxUp Academy LeonardUp Academy OliverUpper School AcademyUpper School (HS)WetherbeeOther:Other(Required)Please select one:My agency is not listed – it is:I do not represent an Agency, I am:My agency is not listed – it is:(Required)I do not represent an Agency, I am:(Required)Project Bethlehem RecipientHead of HouseholdHead of Household's Name(Required) First Last Address(Required) Full street address (required) City (Only if not Lawrence) AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Primary Phone(Required)Alternate PhoneEmail Number in family:(Required) Is there an alternate contact?Is there an alternate contact? Yes Alternate Contact Name First Last Alternate Contact PhoneRelationshipPlease select one:Spouse/partnerSiblingParentGrandparentAunt/UncleFriendOther:Christmas WishHead of HouseholdHead of Household Name(Required) Age(Required) Gender Male Female Other Household Item Gift Card 1Please Select One:AmazonBed Bath BeyondHome DepotKohl’sLowesTargetTJMaxx – HomegoodsWalmartClothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartFamily Game 1Please select one:Apples to ApplesBattleshipBingoBooks- readers , coloring, familyCandylandCard gamesCharadesCheckersChessChutes n' LaddersClueConnect 4CootieDominoesDon't break the iceDon’t make me laughFamily FeudGuess WhoHeads UpHungry Hungry HippoIdeal Hot PotatoJengaJigsaw puzzles, regular or 3DLifeMancalaMonkeys UpMonopolyMonopoly JrMr. Potato HeadOperationParchesiPaw Patrol matching gamePenguins on IcePictionaryPie FaceRiskScattergoriesScrabbleSorrySpot it card gameTabooTrivial PursuitTrivial Pursuit, DisneyTroubleTwisterUnoYahtzeeYeti and my spaghettiOtherFamily Game 2Please select one:Apples to ApplesBattleshipBingoBooks- readers , coloring, familyCandylandCard gamesCharadesCheckersChessChutes n' LaddersClueConnect 4CootieDominoesDon't break the iceDon’t make me laughFamily FeudGuess WhoHeads UpHungry Hungry HippoIdeal Hot PotatoJengaJigsaw puzzles, regular or 3DLifeMancalaMonkeys UpMonopolyMonopoly JrMr. Potato HeadOperationParchesiPaw Patrol matching gamePenguins on IcePictionaryPie FaceRiskScattergoriesScrabbleSorrySpot it card gameTabooTrivial PursuitTrivial Pursuit, DisneyTroubleTwisterUnoYahtzeeYeti and my spaghettiOtherFamily Game Other Description:Is there a Spouse/Partner?Is there a Spouse/Partner? Yes Spouse/PartnerSpouse Name Age Gender Male Female Other Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartDoes an additional adult live here?Does an additional adult live here? Yes Additional Adult 1Name – Additional Adult 1 Age Gender Male Female Other RelationshipPlease select one:Spouse/partnerSiblingParentGrandparentAunt/UncleFriendOther:Relationship Description Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartDoes an additional adult live here?Does an additional adult live here? Yes Additional Adult 2Name – Additional Adult 2 Age Gender Male Female Other RelationshipPlease select one:Spouse/partnerSiblingParentGrandparentAunt/UncleFriendOther:Relationship Description Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartDoes an additional adult live here?Does an additional adult live here? Yes Additional Adult 3Name – Additional Adult 3 Age Gender Male Female Other RelationshipPlease select one:Spouse/partnerSiblingParentGrandparentAunt/UncleFriendOther:Relationship Description Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartDoes an additional adult live here?Does an additional adult live here? Yes Additional Adult 4Name – Additional Adult 4 Age Gender Male Female Other RelationshipPlease select one:Spouse/partnerSiblingParentGrandparentAunt/UncleFriendOther:Relationship Description Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartDoes an additional adult live here?Does an additional adult live here? Yes Additional Adult 5Name – Additional Adult 5 Age Gender Male Female Other RelationshipPlease select one:Spouse/partnerSiblingParentGrandparentAunt/UncleFriendOther:Relationship Description Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartDoes an additional adult live here?Does an additional adult live here? Yes Additional Adult 6Name – Additional Adult 6 Age Gender Male Female Other RelationshipPlease select one:Spouse/partnerSiblingParentGrandparentAunt/UncleFriendOther:Relationship Description Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartDoes an additional adult live here?Does an additional adult live here? Yes Additional Adult 7Name – Additional Adult 7 Age Gender Male Female Other RelationshipPlease select one:Spouse/partnerSiblingParentGrandparentAunt/UncleFriendOther:Relationship Description Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartDoes an additional adult live here?Does an additional adult live here? Yes Additional Adult 8Name – Additional Adult 8 Age Gender Male Female Other RelationshipPlease select one:Spouse/partnerSiblingParentGrandparentAunt/UncleFriendOther:Relationship Description Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartDoes an additional adult live here?Does an additional adult live here? Yes Additional Adult 9Name – Additional Adult 9 Age Gender Male Female Other RelationshipPlease select one:Spouse/partnerSiblingParentGrandparentAunt/UncleFriendOther:Relationship Description Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmart Child 1Name – Child 1(Required) Age(Required) Gender(Required) Male Female Other Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartToy Preference 1 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Toy Preference 2 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Does an additional child live here?Does an additional child live here? Yes Child 2Name – Child 2(Required) Age(Required) Gender(Required) Male Female Other Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartToy Preference 1 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Toy Preference 2 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Does an additional child live here?Does an additional child live here? Yes Child 3Name – Child 3(Required) Age(Required) Gender(Required) Male Female Other Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartToy Preference 1 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Toy Preference 2 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Does an additional child live here?Does an additional child live here? Yes Child 4Name – Child 4(Required) Age(Required) Gender(Required) Male Female Other Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartToy Preference 1 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Toy Preference 2 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Does an additional child live here?Does an additional child live here? Yes Child 5Name – Child 5(Required) Age(Required) Gender(Required) Male Female Other Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartToy Preference 1 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Toy Preference 2 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Does an additional child live here?Does an additional child live here? Yes Child 6Name – Child 6(Required) Age(Required) Gender(Required) Male Female Other Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartToy Preference 1 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Toy Preference 2 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Does an additional child live here?Does an additional child live here? Yes Child 7Name – Child 7(Required) Age(Required) Gender(Required) Male Female Other Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartToy Preference 1 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Toy Preference 2 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Does an additional child live here?Does an additional child live here? Yes Child 8Name – Child 8(Required) Age(Required) Gender(Required) Male Female Other Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartToy Preference 1 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Toy Preference 2 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Does an additional child live here?Does an additional child live here? Yes Child 9Name – Child 9(Required) Age(Required) Gender(Required) Male Female Other Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartToy Preference 1 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Toy Preference 2 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Does an additional child live here?Does an additional child live here? Yes Child 10Name – Child 10(Required) Age(Required) Gender(Required) Male Female Other Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartToy Preference 1 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Toy Preference 2 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Does an additional child live here?Does an additional child live here? Yes Child 11Name – Child 11(Required) Age(Required) Gender(Required) Male Female Other Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartToy Preference 1 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Toy Preference 2 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Does an additional child live here?Does an additional child live here? Yes Child 12Name – Child 12(Required) Age(Required) Gender(Required) Male Female Other Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartToy Preference 1 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Toy Preference 2 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Does an additional child live here?Does an additional child live here? Yes Child 13Name – Child 13(Required) Age(Required) Gender(Required) Male Female Other Clothing Gift CardPlease select one:AmazonKohl'sOld NavyTargetTJ MaxxWalmartToy Preference 1 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Toy Preference 2 (All items should be under $40 and specific size must be included below if applicable (ie diapers, rollerblades, sports shirts, shoes, socks, etc.)Special Note to DonorUse this section if the family wishes to send a note to the donor. Please only press the ‘SUBMIT’ button once. Contact us as soon as possible at projectbethlehem@lazarushouse.org if you don’t receive a confirmation email.NameThis field is for validation purposes and should be left unchanged.
