Shopper Application Form
Please fill out this form to apply as a participant. Please complete an application for each person you have wanting to shop. Each participant must have their own application completed. Please note that the age range for a shopper with a disability is ages 3 and up and for a sibling, the age range will be limited from age 3 to age 12. We welcome any sibling over the age of 12 to sign up as a buddy or volunteer.
Shopper Name
*
First Name
Last Name
Date of Birth of the Shopper
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age of the Shopper
*
Name of Parent or Legal Gaurdian
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number (If you are the parent or legal guardian, please provide your phone number)
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Emergency & Medical Information
This information is for the shopper named at the beginning of the application. Please provide as much information below as possible as it allows us the opportunity to ensure that the shopper has the best buddy available to help them with their needs.
Emergency Contact
*
First Name
Last Name
Relationship to Shopper
What is the disability of the shopper?
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please list any allergies (Food, Medication, Environmental, etc)
*
Please list any and all allergies and the severity of your reactions
Do you carry an EpiPen?
Yes
No
Please list any medications that need to be taken during Joy of Giving (If there are none, please indication that there are none)
*
Please connect with us if medication needs to be administered on-site so we can have someone available to administer the medication.
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Communication & Social Interaction
This information is for the shopper named at the beginning of the application
What is your primary mode of communication?
Verbal (speaks in full sentences)
Verbal (uses short phrases/single words)
Non-verbal (uses gestures, sign language, or communication devices)
Other (Please elaborate below)
If you indicated "Other" above, please elaborate.
Do you have any sensitivities or triggers to the following and elaborate on signs of distress and calming strategies below):
Loud Noices/Music
Bright Lights/Flashing Lights
Crowded/Busy Rooms
Tactile (i.e. glue, sand, paint, etc)
For any sensitivities and triggers you indicated above, what are the early signs that you are becoming frustrated, overwhelmed, or distressed?
What is the best way to help if you are becoming distressed, anxious, or about to have a meltdown?
Do you use any of the following tools? (Please bring them to VBS).
Noice-cancelling headphones
Fidget tools or weighted vests
Visual schedule or pricture cards (PECS)
Mobility Support
Walks independently
Uses a wheelchair (please let us know if your wheelchair is manual or powered)
Uses a walker, crutches, or braces
Needs physical assistance
Restroom Assistance
Fully independent
Needs verbal reminders/prompting
Needs physical assistance
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Please list up to 5 people that each shopper will be getting gifts for. Include name, age, and relationship to the shopper.
The maximum allowed for each shopper is 5. If the shopper has siblings who will be attending, they can shop for any additional people. Limiting the number that each shopper will be shopping for will help with the flow of the event. If you only have one shopper and need more than 5 people on this list, please email us.
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Please list any sibling that will also be shopping
Please complete a shopper application for any siblings listed below
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Permissions & Photo Release
Photo/Video Release - I give permission for my photo to be taken for the church's promotional use (i.e. slideshows, webiste, social media posts, etc.)
*
Yes
No
In the event that there is a medical emergency, I authorize Joy of Giving staff to seek medical attention for me. If so, please sign:
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Application
Submit Application
Should be Empty: