GRACE Christmas Senior's Gift Registration Form

Application Date*

Date

Reason you were not able to attend the sign up day:*

Name*

First NameLast Name

Date of Birth -- must be 55 or older.*

Date

Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone*

Please enter a valid phone number.

Phone Type

CellHome

Other Phone

Please enter a valid phone number.

Phone Type

CellHomeWork

Email

example@example.com

Do you need to have your gifts delivered?*

YesNo

Household size?

Number of family members

*Race (W= White AA= African American H=Hispanic A= Asian NA=Native American O=Other X=Not disclosed)

	Full Name	Race*	Sex	Age	DOB	Shirt Size	Pant Size	Shoe Size	What is the favorite color?
Senior One
Senior Two
Senior Three

Sources of Household Income (Please upload documents).

	Source	Amount	Verified
1
2
3
4

Wish List - please include sizes and gender

	Wish List
Senior One
Senior Two
Senior Three

TERMS AND CONSENT TO RELEASE CONFIDENTIAL INFORMATION:

I understand that this is an outreach program sponsored by Greene Alliance of Church and Community Efforts, Inc. (GRACE) and that it is supported by our local agencies, churches, schools, civic organizations, businesses and individuals in our community. I certify that the information provided is true and correct. I understand that if I have knowingly given false or misleading information in the completion of this application, I can be denied this service. I give Greene Alliance of Church and Community Efforts permission to verify my confidential information with other agencies, schools, employers, etc. I understand that none of this information will be shared or released except for the purposes of evaluating my need for holiday assistance and to confirm residency in Greene County. I understand that the Wish List items are not guaranteed and that this list is intended to serve as a guide to those who wish to contribute to families in need of this assistance. I will be responsible for picking up my gifts from the designated place and during the distribution date and times listed on my card; otherwise, the gifts will be forfeited.

Printed Name of Applicant*

First NameLast Name

Signature*

Date of Signature*

Date

Use this section to upload a copy of your ID and proof of income.

GRACE CHRISTMAS GIFT PROGRAM DISCLAIMER

Welcome to our Christmas Gift Program. The goal of this program is to provide gifts for seniors aged 60 and over.

GRACE has asked you to provide us with some information that we would like to explain:

1. Your picture ID (usually your driver’s license) helps our volunteers verify that you are who you say you are and that you live in Greene County. If your address is not correct on your driver’s license, or does not show your current physical address, please present other proof of your address (e.g., electric bill with your name and address).

2. We have asked that you bring proof of your income. Income includes pay stubs from jobs, child support/alimony, TANF, disability award letters, Social Security award letters, etc. Your income must not exceed 200% of the Continental United States poverty guidelines.

You are responsible for accurate contact information and keeping your phones active in case GRACE needs to contact you for additional information. GRACE's inability to contact you may result in your gift requests not being honored.

If you are requesting that your gift be delivered, please make sure that you will be home during the time that has been arranged for your gift to be dropped off at your home.

Gifts not picked up by closing time on distribution day will be forfeited and given to another family in Greene County needing this assistance. If you designate someone else to pick up your gifts, that person MUST bring your family card AND a letter signed by you authorizing them to pick up your gifts; otherwise, the gifts will not be released to them. The person picking up your gifts will be asked to show their ID. If someone else picks up your gifts on your behalf, GRACE does not guarantee that the gifts you receive are the same as those given to your authorized pick-up person.

In the WISH LIST section of the registration form, please provide a clear explanation of your wishes. If requesting clothing or shoes, please list shirt, pant and shoe sizes. Please avoid listing expensive items over $100. Our sponsors are often on limited incomes too.

Please understand that the WISH LIST serves as a guide for our sponsors as they do their shopping. GRACE cannot guarantee that you will receive everything you put down. Please allow extra pick up time on distribution day as you are likely to experience a wait.

I understand that the terms of this registration form and have received a copy of the above disclaimer terms.

CLIENT'S INITIALS: