Project Bethlehem Recipient Form Project Bethlehem - 2023 Form "*" indicates required fields Step 1 of 6 - Preparer 16% Preparer's InformationPreparer's Name* First Last Preparer Email* Phone*Date* MM slash DD slash YYYY Are you from a school or agency?* School Agency Referral Source (Agencies)*Please select one:Community Day Care/Teen Parent ProgramDepartment of Children & FamiliesDepartment of Mental HealthFamily ContinuityFamily Services of MV, Young Empowered ParentProgram (YEP)Families & Youth Initiative (PATCH)GLCAC Head StartGLCAC Community and Family Support CenterGreater Lawrence Family Health CenterJeanne Geiger Crisis Center Family SafetyJRI/Children’s Friend and Family ServicesKid-Start, Inc.Lazarus House, Capernaum PlaceMentor South Bay Early InterventionMSPCC/Healthy FamiliesNotre Dame Educational CenterPartners in Child DevelopmentSaunders School ApartmentsSi Se PuedeSupportive CareUtecReferral Source (Schools)*Please select one:Arlington ElementaryArlington MiddleBreenBruceCommunity Day Charter SchoolsFrost ElementaryGuilmetteHennessey SchoolHLC - High School Learning CenterLawlorLawrence Family Public AcademyLawrence High SchoolLeahyLeonardOliver ElementaryOliver Middle/Up Academy OliverParthum ElementaryParthum MiddlePhoenix AcademyRISERollins Early ChildhoodSchool for Exceptional Studies (SES)SES ANNEXSouth Lawrence EastSpark AcademyTarboxUnidosWetherbeeMy school is not listed, it is: Project Bethlehem RecipientHead of Household's Name* First Last Address* Street Address Address Line 2 City (if NOT Lawrence) State MassachusettsAlabamaAlaskaAmerican 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 Primary Phone*Secondary Phone (if available)Email Number in Family*Is there an alternate contact? Yes Alternate Contact's Name* First Last Alternate Contact's Phone* Christmas Wish: Heads of HouseholdName* Age (if known) Gender (optional) Male Female Other Household Item Gift Card*Please select oneAmazonHome DepotKohl'sLowesTargetTJMaxx - Home GoodsWalmartClothing Gift Card*Please select oneAmazonKohl'sOld NavyTargetTJ MaxxWalmartFamily Game 1*Please select oneApples to ApplesBattleshipBingoCandylandCard GamesCheckersChessChutes and LaddersClueConnect 4CootieDominoesDon’t Break the IceGuess WhoHedbanzHungry Hungry HippoesJengaJigsaw PuzzlesLifeMancalaMonopolyMonopoly, Jr.OperationParcheesiPictionaryRiskScattergoriesScrabbleSorrySpot ItTrivial PursuitTrivial Pursuit, DisneyTroubleTwisterUnoYahtzeeOtherFamily Game 2*Please select oneApples to ApplesBattleshipBingoCandylandCard GamesCheckersChessChutes and LaddersClueConnect 4CootieDominoesDon’t Break the IceGuess WhoHedbanzHungry Hungry HippoesJengaJigsaw PuzzlesLifeMancalaMonopolyMonopoly, Jr.OperationParcheesiPictionaryRiskScattergoriesScrabbleSorrySpot ItTrivial PursuitTrivial Pursuit, DisneyTroubleTwisterUnoYahtzeeOtherFamily Game Other 1* Family Game Other 2* Is there a Spouse/Partner?* Yes No Spouse Name* Age (if known) Gender (optional) Male Female Other Clothing Gift Card*Please select oneAmazonKohl'sOld NavyTargetTJ MaxxWalmart Add Additional Adults Name Age (if known) Gender (optional) Relationship Clothing Gift Card Actions Edit Delete There are no Records. Add Record Maximum number of records reached. Add Children Name Age Gender Clothing Gift Card Toy Preference 1 Toy Preference 2 Actions Edit Delete There are no Records. Add Record Maximum number of records reached. Special Note to DonorUntitledUse 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.
