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$50K YOUR WAY
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Adopt-a-Family Wishlist Form
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Our Funded Agencies
2025 Funding Application
Reporting
Charity Tracker
Login
Volunteer
Volunteer Response Center (VRC)
2024 Volunteer Calender
2024 Campaign
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VISTA Application
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2024 Employee Workplace Campaign
Home
Christmas Adopt a Family - Family Wishlist
Christmas Adopt a Family - Family Wishlist
Current
Family Details
Parent Details
Child Details
Signature Details
Complete
This is the first time my family has participated in the United Way's Christmas Adopt a Family Program
This box must be checked in order to proceed with this application. Repeat families will not be accepted.
Today's Date:
Referred By:
Family Information
Family Contact Name
Contact Method
- Select -
Phone
Email
Family Contact Phone Number
Family Contact Email
Alternate Contact Name
Contact Method
- Select -
Phone
Email
Alternate Contact Phone Number
Alternate Contact Email
Family Physical Address
Street Name
Number of House or Building or Apartment
City/Town
ZIP/Postal Code
Family Mailing Address (if different)
Address
Address 2
City/Town
ZIP/Postal Code
Family Members
Children in Family
Class of Hardship
Class of Hardship
- Select -
Catastrophic Injury
Catastrophic Illness
Chronic Pain
Chronic Fatigue
Loss of Income
Loss of Home
Custody Responsibility
Other…
Enter other…
Family Story (please do not include names for privacy)
Add a Child?
Yes
No
Child 7
Name of Child
Child Sex
- Select -
Male
Female
Child Race
Child Race
- Select -
Black / African American
White / Caucasian
Hispanic or Latino
Two or more
Asian
Native American
Hawaiian / Pacific Islander
Other…
Enter other…
Years
Months
Diaper Size
Height
Weight
Shirt/Blouse Size
Pant/Skirt Size
Jacket/Coat Size
Suit/Dress Size
Shoe Size
Child Needs
Child Wants
Child Wish
Add a Child?
Yes
No
Child 8
Name of Child
Child Sex
- Select -
Male
Female
Child Race
Child Race
- Select -
Black / African American
White / Caucasian
Hispanic or Latino
Two or more
Asian
Native American
Hawaiian / Pacific Islander
Other…
Enter other…
Years
Months
Diaper Size
Height
Weight
Shirt/Blouse Size
Pant/Skirt Size
Jacket/Coat Size
Suit/Dress Size
Shoe Size
Child Needs
Child Wants
Child Wish
Add a Child?
Yes
No
Child 9
Name of Child
Child Sex
- Select -
Male
Female
Child Race
Child Race
- Select -
Black / African American
White / Caucasian
Hispanic or Latino
Two or more
Asian
Native American
Hawaiian / Pacific Islander
Other…
Enter other…
Years
Months
Diaper Size
Height
Weight
Shirt/Blouse Size
Pant/Skirt Size
Jacket/Coat Size
Suit/Dress Size
Shoe Size
Child Needs
Child Wants
Child Wish
Add a Child?
Yes
No
Child 10
Name of Child
Child Sex
- Select -
Male
Female
Child Race
Child Race
- Select -
Black / African American
White / Caucasian
Hispanic or Latino
Two or more
Asian
Native American
Hawaiian / Pacific Islander
Other…
Enter other…
Years
Months
Diaper Size
Height
Weight
Shirt/Blouse Size
Pant/Skirt Size
Jacket/Coat Size
Suit/Dress Size
Shoe Size
Child Needs
Child Wants
Child Wish
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