Project Bethlehem Recipient Form

Preparer

Name*

First Last

Email*

Phone*

Date*

Referral Source (Agencies)

Referral Source (Schools)

Other:

Project Bethlehem Recipient

Head of Household

Name*

First Last

Address*

Street Address Address Line 2 City 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

Name

Age

Gender

Male
Female
Other

Household Item Gift Card 1

Household Item Gift Card 2

Clothing Gift Card

Family Game 1

Family Game 2

Family Game Other Description:

Is there a Spouse/Partner?

Yes

Spouse/Partner

Name

Age

Gender

Male
Female
Other

Clothing Gift Card

Does an additional adult live here?

Yes

Additional Adult

Name

Age

Gender

Male
Female
Other

Relationship

Relationship Description

Clothing Gift Card

Child 1

Name*

Age*

Gender*

Male
Female
Other

Clothing Gift Card

Toy Preference 1 (No Expensive Electronics)

Toy Preference 2 (No Expensive Electronics)

Special Note to Donor

What does your family want the Donor to know about them?

Email

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