Project Bethlehem Recipient Form

Preparer

Preparer's Name*

First Last

Email*

Phone*

Date*

Referral Source (Agencies)

Referral Source (Schools)

Other:

Project Bethlehem Recipient

Head of Household

Head of Household's Name*

First Last

Address*

Full street address (required)

Address Line 2 (Optional) City (Optional) State

Primary Phone*

Alternate Phone

Email

Number in family:*

Is there an alternate contact?

Yes

Alternate Contact Name

First Last

Alternate Contact Phone

Relationship

Christmas Wish

Head of Household

Head of Household Name*

Age*

Gender

Male
Female
Other

Household Item Gift Card 1

Clothing Gift Card

Family Game 1

Family Game 2

Family Game Other Description:

Is there a Spouse/Partner?

Yes

Spouse/Partner

Spouse Name

Age

Gender

Male
Female
Other

Clothing Gift Card

Does an additional adult live here?

Yes

Additional Adult 1

Name - Additional Adult 1

Age

Gender

Male
Female
Other

Relationship

Relationship Description

Clothing Gift Card

Does an additional adult live here?

Yes

Additional Adult 2

Name - Additional Adult 2

Age

Gender

Male
Female
Other

Relationship

Relationship Description

Clothing Gift Card

Does an additional adult live here?

Yes

Additional Adult 3

Name - Additional Adult 3

Age

Gender

Male
Female
Other

Relationship

Relationship Description

Clothing Gift Card

Does an additional adult live here?

Yes

Additional Adult 4

Name - Additional Adult 4

Age

Gender

Male
Female
Other

Relationship

Relationship Description

Clothing Gift Card

Does an additional adult live here?

Yes

Additional Adult 5

Name - Additional Adult 5

Age

Gender

Male
Female
Other

Relationship

Relationship Description

Clothing Gift Card

Does an additional adult live here?

Yes

Additional Adult 6

Name - Additional Adult 6

Age

Gender

Male
Female
Other

Relationship

Relationship Description

Clothing Gift Card

Does an additional adult live here?

Yes

Additional Adult 7

Name - Additional Adult 7

Age

Gender

Male
Female
Other

Relationship

Relationship Description

Clothing Gift Card

Does an additional adult live here?

Yes

Additional Adult 8

Name - Additional Adult 8

Age

Gender

Male
Female
Other

Relationship

Relationship Description

Clothing Gift Card

Does an additional adult live here?

Yes

Additional Adult 9

Name - Additional Adult 9

Age

Gender

Male
Female
Other

Relationship

Relationship Description

Clothing Gift Card

Child 1

Name - Child 1*

Age*

Gender*

Male
Female
Other

Clothing Gift Card

Toy Preference 1 (No Expensive Electronics)

Toy Preference 2 (No Expensive Electronics)

Does an additional child live here?

Yes

Child 2

Name - Child 2*

Age*

Gender*

Male
Female
Other

Clothing Gift Card

Toy Preference 1 (No Expensive Electronics)

Toy Preference 2 (No Expensive Electronics)

Does an additional child live here?

Yes

Child 3

Name - Child 3*

Age*

Gender*

Male
Female
Other

Clothing Gift Card

Toy Preference 1 (No Expensive Electronics)

Toy Preference 2 (No Expensive Electronics)

Does an additional child live here?

Yes

Child 4

Name - Child 4*

Age*

Gender*

Male
Female
Other

Clothing Gift Card

Toy Preference 1 (No Expensive Electronics)

Toy Preference 2 (No Expensive Electronics)

Does an additional child live here?

Yes

Child 5

Name - Child 5*

Age*

Gender*

Male
Female
Other

Clothing Gift Card

Toy Preference 1 (No Expensive Electronics)

Toy Preference 2 (No Expensive Electronics)

Does an additional child live here?

Yes

Child 6

Name - Child 6*

Age*

Gender*

Male
Female
Other

Clothing Gift Card

Toy Preference 1 (No Expensive Electronics)

Toy Preference 2 (No Expensive Electronics)

Does an additional child live here?

Yes

Child 7

Name - Child 7*

Age*

Gender*

Male
Female
Other

Clothing Gift Card

Toy Preference 1 (No Expensive Electronics)

Toy Preference 2 (No Expensive Electronics)

Does an additional child live here?

Yes

Child 8

Name - Child 8*

Age*

Gender*

Male
Female
Other

Clothing Gift Card

Toy Preference 1 (No Expensive Electronics)

Toy Preference 2 (No Expensive Electronics)

Does an additional child live here?

Yes

Child 9

Name - Child 9*

Age*

Gender*

Male
Female
Other

Clothing Gift Card

Toy Preference 1 (No Expensive Electronics)

Toy Preference 2 (No Expensive Electronics)

Does an additional child live here?

Yes

Child 10

Name - Child 10*

Age*

Gender*

Male
Female
Other

Clothing Gift Card

Toy Preference 1 (No Expensive Electronics)

Toy Preference 2 (No Expensive Electronics)

Does an additional child live here?

Yes

Child 11

Name - Child 11*

Age*

Gender*

Male
Female
Other

Clothing Gift Card

Toy Preference 1 (No Expensive Electronics)

Toy Preference 2 (No Expensive Electronics)

Does an additional child live here?

Yes

Child 12

Name - Child 12*

Age*

Gender*

Male
Female
Other

Clothing Gift Card

Toy Preference 1 (No Expensive Electronics)

Toy Preference 2 (No Expensive Electronics)

Does an additional child live here?

Yes

Child 13

Name - Child 13*

Age*

Gender*

Male
Female
Other

Clothing Gift Card

Toy Preference 1 (No Expensive Electronics)

Toy Preference 2 (No Expensive Electronics)

Special Note to Donor

Use this section if the family wishes to send a note to the donor.

Email

This field is for validation purposes and should be left unchanged.