Clothe a Child Interest Form

Clothe a Child Interest Form
Parent/Guardian Contact Information
Parent/Guardian Name*

First NameLast Name
Email*
example@example.com
Parent/Guardian Date of Birth*

MonthDayYear
Date
Parent/Guardian Ethnicity (optional)

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhite or CaucasianOther
Parent/Guardian Gender*

MaleFemale
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Each family will be asked to contribute $10 back into the Clothe a Child program to support future families.*

I understand I will be asked to contribute $10
Briefly describe why you need clothing help for your children*
Have you or your kids participated in a Kroc program before?*

NoYes, Clothe a ChildYes, Camp KrocYes, Mobile KrocYes, The WellOther
Child #1 Name*

First NameLast Name
Child #1 Date of Birth*

MonthDayYear
Child #1 Sex*

MaleFemaleN/A
What School District is your child in? *
Please list the top 5 items your child needs
Do you have more children to sign up?*

YesNo
Child #2 Name

First NameLast Name
Child #2 Date of Birth

MonthDayYear
Child #2 Sex

MaleFemaleN/A
What School District is your child in?
Please list the top 5 items your child needs
Do you have more children to sign up?

YesNo
Child #3 Name

First NameLast Name
Child #3 Date of Birth

MonthDayYear
Child #3 Sex

MaleFemaleN/A
What School District is your child in?
Please list the top 5 items your child needs
Do you have more children to sign up?

YesNo
Child #4 Name

First NameLast Name
Child #4 Date of Birth

MonthDayYear
Child #4 Sex

MaleFemaleN/A
What School District is your child in?
Please list the top 5 items your child needs
Emergency Contact
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Parent/Guardian*
Would you be willing to share your story?

Due to the sensitive nature of this program, we understand that not everyone will want their story made public. However, stories of life change make a difference in our community in a number of ways! They can help other people see that it's okay to reach out for help, they can help donors see what their donations are doing in the community, they can help gather more donations so more families can participate in this event, and so much more.

If you're willing to share your story with us, a member from the Kroc Marketing Team will join you on your shopping day, interview you, and take some photos.

If you have any questions, don't hesitate to ask!
I'm willing to share my story and be interviewed and photographed by a Kroc Center employee and I have read the above statement.*

YesNoMaybe, but I have some questions
Should be Empty:

Clothe a Child Interest Form

Parent/Guardian Contact Information

Emergency Contact