Christmas Adopt a Family - Family Wishlist | United Way of the Golden Triangle Region

Current Family Details
Parent Details (Only one adult allowed)
Child Details
Signature Details
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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:

*YOU CAN NOT REFER YOURSELF and YOU MUST live in Clay, Choctaw, Lowndes, Noxubee, Oktibbeha, Webster or Winston Counties Mississippi to participate.

Family Information

Family Contact Name

Contact Method

Family Contact Phone Number

Family Contact Email

Alternate Contact Name

Contact Method

Alternate Contact Phone Number

Alternate Contact Email

Street Name

Number of House or Building or Apartment

City/Town

ZIP/Postal Code

Address

Address 2

City/Town

ZIP/Postal Code

Family Members

Children in Family

Class of Hardship

Family Story (please do not include names for privacy)