2023 Family Promise Holiday Toy Distribution Form

1
I have already applied for Christmas assistance with another organization, agency or individual.
YESNO
2
I understand that it is a requirement of this program that I show a picture ID for all adults and a Forward Health or Social Security card for each child. I understand that I will be required to provide a current utility bill to verify my address in Eau Claire County.
YESNO
3
I understand that no families will be matched with individual sponsors, and I must be present at one of the 3 shopping days to receive gifts for my family.
YESNO
4
Would your family like a translator to assist you on shopping day?
YESNO
5
What is your preferred language?
Hmong
Spanish
Other
6
Parent / Caregiver Last Name* This field is required.
7
Parent / Caregiver First Name * This field is required.
8
Contact Phone Number* This field is required.
Area Code
Phone Number
9
E-mail Address* This field is required.
10
Is there a second parent / caregiver?
YESNO
11
Parent / Caregiver #2 Last Name
12
Parent / Caregiver #2 First Name
13
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
14
Child 1* This field is required.
First Name
Last Name
15
Child 1 Date of Birth* This field is required.
Date
Month
Day
Year
16
Child 2
First Name
Last Name
17
Child 2 Date of Birth
Date
Month
Day
Year
18
Child 3
First Name
Last Name
19
Child 3 Date of Birth
Date
Month
Day
Year
20
Child 4
First Name
Last Name
21
Child 4 Date of Birth
Date
Month
Day
Year
22
Child 5
First Name
Last Name
23
Child 5 Date of Birth
Date
Month
Day
Year
24
Child 6
First Name
Last Name
25
Child 6 Date of Birth
Date
Month
Day
Year
26
Child 7
First Name
Last Name
27
Child 7 Date of Birth
Date
Month
Day
Year
28
Child 8
First Name
Last Name
29
Child 8 Date of Birth
Date
Month
Day
Year
30
Child 9
First Name
Last Name
31
Child 9 Date of Birth
Date
Month
Day
Year
32
Child 10
First Name
Last Name
33
Child 10 Date of Birth
Date
Month
Day
Year
34
Child 11
First Name
Last Name
35
Child 11 Date of Birth
Date
Month
Day
Year
36
Child 12
First Name
Last Name
37
Child 12 Date of Birth
Date
Month
Day
Year
38
Child 13
First Name
Last Name
39
Child 13 Date of Birth
Date
Month
Day
Year
40
Child 14
First Name
Last Name
41
Child 14 Date of Birth
Date
Month
Day
Year
42
Child 15
First Name
Last Name
43
Child 15 Date of Birth
Date
Month
Day
Year
44
Electronic Signature* This field is required.By signing this form I give FPCV permission to share mine and my children's names and information with other agencies and volunteers for the purpose of distributing Festival of Toys donations. This information is true and correct to the best of my knowledge, I understand that the program is voluntary and I understand and agree to the terms of this program.
First and Last Name
45
DateTime
46
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