OPTIONS 2014 Christmas Hamper Application

Application Deadline is NOVEMBER 17TH

(ARRANGEMENTS FOR PICK-UP & DROP-OFF BY STAFF FROM DEC. 08 -19)

Name (first name only)

Gender

Parent/Guardian

Parent/Guardian:

Child 1:

Child 2: r

Child 3:

Child 4:

Child 5:

Age

Shoes
Sizes

Clothing
Sizes

Gift Ideas
(details)

Single

Additional Information Regarding Family Needs:

PROGRAM INFORMATION (please fill in completely or application will not be processed):
Program Name (no acronyms):
Referring Worker:

Phone #:

E-mail:

Cell #:

Program Manager:

Phone #:

E-mail:

Cell #:

Ext.

Ext.

CLIENT INFORMATION:
Name (first & last):
Address:

*PLEASE NOTE: By filling out this document the client is giving consent to release their information to the Surrey Christmas
Bureau PO Box 547, 10688 King George Blvd, Surrey, BC V3T 5W7

OFFICE USE ONLY

Sponsor:

Phone #:

Address:

E-mail:

Hamper was pickedup/dropped-off on

by

AMOUNT OF GIFT
CERTIFICATE

PLEASE SIGN UPON DELIVERY OF HAMPER

(if applicable)

Worker Signature:
Program Manager:
$

Client Signature:

Please forward completed electronic application to your Program Manager

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