Letter to Santa and Supplemental Information

Language:
Name:  
Address:  
City:  
State:  
Zip:    
Phone:  
Email:    
Letter to Santa:      2500 characters remaining
1) Are you working with an agency?
Which one:
One form and letter will be accepted per address You must provide proof of residency.
2) How many are living in the home?
Adults:    
Children (under 16):    
Total:    
3) Please choose one:   
4) Income Source:  
Employed:
Calworks:
Calfresh:
SSI:
SS:
UIB:
Other:
5) Have you had unexpected expenses? (Car repair, medical, job loss, home repair, school) Please provide documentation and /or explain
6) How did you hear about Secret Santa?
KZST:
Volunteer Center:
211:
Friend:
7) Did you receive a Secret Santa gift in:
2011:
2012:
2013:
2014:
8) Please select your top 3 greatest needs this year. Please indicate with most (1) important to least (3) important.
Need Toys:  
Need Clothes:  
Need Shoes:  
Need Food:  
Need Utilities:  
Need Transportation:  
Need Home Repairs:  
Need Dental:  
Need Medical:  
Need Rent:  
Need Other:  
9) Please note your letter will not be processed until this application has been returned. Application submission does not guarantee you will receive items from Secret Santa. Secret Santa does its best to get items to recipients before 12/23, but some letters will not be filled by that date or may be filled in January. Items that exceed $25 may be delayed until February. Secret Santa will contact recipients once letter has been fulfilled and to make arrangements for pick-up. ID will be required to pick up gifts.
10) By submitting this form, I allow the Secret Santa Program (Volunteer Center, Volunteers, KZST and Friedman’s Home Improvement) to share the information I have provided. I understand that completing this application does not guarantee the receiving of any gifts or food vouchers, and the quality and quantity of the gifts is dependent upon the generosity of donors. I agree to pick up gifts by 1/15/2018 if I am granted or forfeit following year. I hereby give permission to release this information to Secret Santa for marketing and verification of information.
By clicking the 'Send Letter' button below, you confirm the terms specified above:
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Please be advised that making a request for an item does not guarantee that you will receive those items. They are only to serve as suggestions for donors.
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