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Outreach Christmas Sign-up Form
This application is for Polk County Residents only who are 65 years or older or have children in the home between the ages of 0-18
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Physical Address only
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Parent/Guardian Date of Birth
*
Gender
*
Male
Female
How many individuals currently live in the home?
*
Do you have a Child between the ages of 0-18 still attending school or an Adult 65 years of age or older in the home?
*
Yes
No
How many Adults are in the home that are 65 years of age or older?
*
How many Children are in the home between the ages of 0 to 18 years of age that are still attending school?
*
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Christmas Gift Applicant One
#1 Child or Adults Full Name
*
Gender
*
Male
Female
Relationship to Head of Household
*
Date of Birth
*
Age
*
Select your choice of gift card
*
Please Select
Please Select
Amazon
Belk's
Dollar General
Family Dollar
GameStop
Old Navy
Target
Wal-Mart
Do you have another Child between the ages of 0-18 still attending school or an Adult 65 years of age or older in the home?
*
Yes
No
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Next
Christmas Gift Applicant Two
# 2 Child or Adults Full Name
*
Gender
*
Male
Female
Relationship to Head of Household
*
Date of Birth
*
Age
*
Select your choice of gift card
*
Please Select
Amazon
Belk's
Dollar General
Family Dollar
GameStop
Old Navy
Target
Wal-Mart
Do you have another Child between the ages of 0-18 still attending school or an Adult 65 years of age or older in the home?
*
Yes
No
Back
Next
Christmas Gift Applicant Three
#3 Child or Adults Full Name
*
Gender
*
Male
Female
Relationship to Head of Household
*
Date of Birth
*
Age
*
Select your choice of gift card
*
Please Select
Amazon
Belk's
Dollar General
Family Dollar
GameStop
Old Navy
Target
Wal-Mart
Do you have another Child between the ages of 0-18 still attending school or an Adult 65 years of age or older in the home?
*
Yes
No
Back
Next
Christmas Gift Applicant Four
#4 Child or Adults Full Name
*
Gender
*
Male
Female
Relationship to Head of Household
*
Date of Birth
Age
*
Select your choice of gift card
*
Please Select
Amazon
Belk's
Dollar General
Family Dollar
GameStop
Old Navy
Target
Wal-Mart
Do you have another Child between the ages of 0-18 still attending school or an Adult 65 years of age or older in the home?
*
Yes
No
Back
Next
Christmas Gift Applicant Five
#5 Child or Adults Full Name
*
Gender
*
Male
Female
Relationship to Head of Household
*
Date of Birth
*
Age
*
Select your choice of gift card
*
Please Select
Amazon
Belk's
Dollar General
Family Dollar
GameStop
Old Navy
Target
Wal-Mart
Do you have another Child between the ages of 0-18 still attending school or an Adult 65 years of age or older in the home?
*
Yes
No
Back
Next
Christmas Gift Applicant Five
#6 Child or Adults Full Name
*
Gender
*
Male
Female
Relationship to Head of Household
*
Date of Birth
*
Age
*
Select your choice of gift card
*
Please Select
Amazon
Belk's
Dollar General
Family Dollar
GameStop
Old Navy
Target
Wal-Mart
Do you have another Child between the ages of 0-18 still attending school or an Adult 65 years of age or older in the home?
*
Yes
No
Back
Next
Christmas Gift Applicant Six
#7 Child or Adults Full Name
*
Gender
*
Male
Female
Relationship to Head of Household
*
Date of Birth
*
Age
*
Select your choice of gift card
*
Please Select
Amazon
Belk's
Dollar General
Family Dollar
GameStop
Old Navy
Target
Wal-Mart
Do you have another Child between the ages of 0-18 still attending school or an Adult 65 years of age or older in the home?
*
Yes
No
Back
Next
Christmas Gift Applicant Seven
#8 Child or Adults Full Name
*
Gender
*
Male
Female
Relationship to Head of Household
*
Date of Birth
*
Age
*
Select your choice of gift card
*
Please Select
Amazon
Belk's
Dollar General
Family Dollar
GameStop
Old Navy
Target
Wal-Mart
Do you have another Child between the ages of 0-18 still attending school or an Adult 65 years of age or older in the home?
*
Yes
No
Back
Next
Christmas Gift Applicant Eight
#9 Child or Adults Full Name
*
Gender
*
Male
Female
Relationship to Head of Household
*
Date of Birth
*
Age
*
Select your choice of gift card
*
Please Select
Amazon
Belk's
Dollar General
Family Dollar
GameStop
Old Navy
Target
Wal-Mart
Do you have another Child between the ages of 0-18 still attending school or an Adult 65 years of age or older in the home?
*
Yes
No
Back
Next
Christmas Gift Applicant Nine
#10 Child or Adults Full Name
*
Gender
*
Male
Female
Relationship to Head of Household
*
Date of Birth
*
Age
*
Select your choice of gift card
*
Please Select
Amazon
Belk's
Dollar General
Family Dollar
GameStop
Old Navy
Target
Wal-Mart
Back
Next
Outreach would like to know the toys that your child has requested for Christmas. Please, list those toys below. Example: Barbie, Moana doll, Monopoly, or a Soccer ball.
*
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Choose a date and time to pick up your Christmas Gifts by clicking calendar and time
Christmas Distribution will start December 5th and end on December 7th. You may select a date and time to pick-up your gifts from 76 North Peak St. Columbus, NC 28722.
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I, undersigned, agree with the following statements:
*
I am the parent/guardian of the children listed on the application.
I understand that I must be a Polk County resident to participate in the Christmas Program.
Outreach cannot guarantee you will receive the gift card of your choice.
The information I have provided is accurate, and I understand that giving information that is not accurate can affect my assistance with the Christmas Program.
I understand that I must provide reliable contact information in the event staff need to notify you of Christmas distribution changes.
I understand that appointments are required for picking up gifts, and if you cannot keep your appointment, you must contact Outreach and speak with Michelle Reedy to reschedule your appointment.
I understand that if I do not keep my appointment and do not reschedule an appointment, I will not be able to pick up gifts outside the dates of December 5th through December 7th.
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