Welcome

1

Parent/Guardian Email

2

Parent/Guardian Phone Number

3

What is your Address?

4

Preferred Contact Method

Email

Phone (Text)

Phone (Call)

5

Please list the names and ages of everyone that lives in your household, including adults.

7

Who from the organization you selected referred you? Enter NA if you answered 'Other' to the previous question.

8

If you selected 'Other' on the previous question, please explain how you heard about us and provide three names and contact details of people who can vouch for your situation. (Note: These 3 people cannot be of any relation)

9

What is the first name of your child?

10

Give a description of your child e.g. Age, Interests, personality etc...

11

What would you like to get your child for Christmas? Please enter specific items and a link to the item if possible. If you do not have a specific idea, click this link for some great gift ideas: https://www.fatbraintoys.com/catalog/(Note: we do not provide phones, ipads or computers. If the request is clothes/shoes, specify what clothes/shoes, sizes etc)

12

Do you have a Christmas Tree?

YESNO

13

Would you like to bring your children to see Santa Claus?(Note: Limited availability)

YESNO

14

While we would love to provide gifts to everyone, unfortunately that is not always possible. The purpose of the Zuzu's Petals is to provide gifts to children who otherwise would not receive any. Please provide a brief rundown on why you require our assistance this Christmas season:

15

By clicking the below checkbox, I consent for the Zuzu’s Petals to provide a gift for the child mentioned in this application based on the information I have provided. I do not give Zuzu’s Petals permission to use the above information for any reason other than to provide a gift for my dependent.

I give consent

I do not give consent

16

Please verify that you are human* This field is required.