Intake 2022 - Homeless Engagement Life Partnership

Welcome to Project R.E.A.C.H.’s Adopt-A-Family program intake process for the 2022 Christmas season.

Congratulations you have been chosen to be part of the 2022 Adopt A Family Program. H.E.L.P. focuses on helping families in need and we would like to see how we may be of service to your family this Christmas. We are EXCITED to have you a part of our program this year, and we look forward to getting to know more about you and your family. Disclaimer: This program is by invitation only and not to be shared with others. If shared you may revoke you and your families opportunity to take part in this years program.

HOW THE PROGRAM WORKS AND WHAT YOU CAN EXPECT:

Once your intake is completed and approved by the deadline given, a host will be assigned to your family. A host is a person or company that signs up and will adopt your family this Christmas season. Once your family is assigned with a host, The host(s) will do their best to serve your family according to the needs, would like to have, and current circumstances. If any additional information is needed, we will reach out to the primary contact person based on your intake. Please make sure to be as SPECIFC as possible. Once the shopping is complete and the gifts are all wrapped, we will be delivering your Christmas gifts to you and your family on a designated date. You will receive a notice of the date and time of the delivery. If possible, have the whole family at home when Santa and his elves delivers YOUR gifts.

GENERAL INFORMATION

Main Contact Person *

First

Last

Main Contact's Phone Number *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Do you live in a Apartment ? If YES please specify below. *

Apartment number and Exact Location in Complex if applicable

FAMILY’S CURRENT CIRCUMSTANCES

This portion of the intake form is where you tell us a little more about your family and your current situation. H.E.L.P. has quite a few resources, and the more we know about your current circumstance, the more we may be able to help out your family with the resources we have. Our Adopt-A-Family program is unique because we focus on providing families with a hand up in their current circumstances, and we do that by getting to know more about who you and your family are. The hosts that adopt a family are interested in knowing more about your family in ways that may go beyond gifts, so please provide as much detail in your answers below.

If an adult in the home is currently looking for work, list their Name what type of work and what work experience they have?

Does the family have a working vehicle? *

How will your family benefit from this program? *

WHAT IS THE SIZE OF THE FAMILY? *

Total number of adults (18 and older) plus the total number of children in the family?

1ST FAMILY MEMBER'S INFORMATION

Please be as specific as possible when filling out the next portion of the intake form. Be as detailed as possible in describing what each family member really needs and what they would really want for Christmas not to exceed $50.00 per gift, and please stay away from putting gift cards down as a choice.

Family Member's First Name *

Adult #1 (18 years and older) ? *

Adult 18+
Teenager 13-17
Child 3-12
Toddler 0-2

Please give EXACT age *

Gender #1 *

Male
Female

When inputting the sizes for clothing and shoes, please also provide the appropriate department so that we get the right size for each family member.

Specific Size Guideline to reference to: M-Men's Xtra SMALL -Top Sizes 30-33 - Waist 26/29 *SMALL-Top Sizes 34-37 - Waist 30/33 *MEDIUM- Top Sizes 38-41 - Waist 34/37 *LARGE Top Sizes 42-45 Waist 38/41 *XL Top Sizes 46-48 Waist 42/45 *2XL-Sizes 50-52 Waist 46/49 *3XXL-sizes 54-56 Waist 50/53 ** WOMEN'S XS (Xtra SMALL)- Top Sizes 0-2/ Waist 24/25 *SMALL- Top Sizes 4-6/ Waist 26/27 *MEDIUM-Sizes 8-10 Waist 28/29 LARGE-sizes 12-14 Waist 30/31 XL- sizes 16-18 Waist 32/33 2XXL- sizes 20-22 Waist 34/35 3XXXL-sizes 24-26 Waist 36/37 4XXXXL- sizes 28-32 Waist 38/39 ** YOUTH/JUNIOR- Xtra SMALL sizes 0-1 SMALL- sizes 3-5 MEDIUM- sizes 7-9 LARGE- sizes 11-13 Xtra LARGE- size 15-17 ** CHILDREN Size 4C- Ages 3 to 4 Size 5C- Ages 4 to 5 Size 6C- Ages 5 to 6 Sizes 6X/7- Ages 6 to 7 * TODDLER 2T-5T * INFANTS 0-24 months

Clothing Department *

Clothing Sizes *

Shirt/Top Size *

Pants/Bottom Size: *

Please give EXACT size for Mens need the Waist X Length

Different Shoe Sizes:

Men’s shoe sizes 6-16 Women’s shoe sizes: 4-13 Youth (7-12) shoe sizes: 3.5-7 Children (5-7 ) shoe sizes: 10.5-3 Toddlers (9mo-4 years) shoe sizes: 3.5-10 Infants (0-9mo) shoe sizes: 0-3

Shoe Department: *

Shoe Size: *

Please give EXACT Size

Shoe Width: *

What are you in need of this Christmas? *

What essentials do you need (clothes, jackets, shoes etc)? Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

What would you like to get for Christmas? *

Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

2ND FAMILY MEMBER'S INFORMATION

Family Member's First Name *

Adult #2 (18 years and older) or Child #2? *

Adult 18+
Teenager 13-17
Child 3-12
Toddler 0-2

Please give EXACT age *

Gender #2 *

Male
Female

When inputting the sizes for clothing and shoes, please also provide the appropriate department so that we get the right size for each family member.

Clothing Department #2 *

Clothing Sizes #2 *

Shirt/Top Size #2 *

Pants/Bottom Size: #2 *

Please give EXACT size for Mens need the Waist X Length

Different Shoe Sizes: #2

Men’s shoe sizes 6-16 Women’s shoe sizes: 4-13 Youth (7-12) shoe sizes: 3.5-7 Children (5-7 ) shoe sizes: 10.5-3 Toddlers (9mo-4 years) shoe sizes: 3.5-10 Infants (0-9mo) shoe sizes: 0-3

Shoe Department: #2 *

Shoe Size: #2 *

Please give EXACT Size

Shoe Width: #2 *

What are you in need of this Christmas? #2 *

What essentials do you need (clothes, jackets, shoes etc)? Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

What would you like to get for Christmas? #2 *

Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

3rd FAMILY MEMBER'S INFORMATION

Family Member's First Name #3 *

Adult #3 (18 years and older) or Child #3? *

Adult 18+
Teenager 13-17
Child 3-12
Toddler 0-2

Please give EXACT age *

Gender #3 *

Male
Female

When inputting the sizes for clothing and shoes, please also provide the appropriate department so that we get the right size for each family member.

Clothing Department #3 *

Clothing Sizes #3 *

Shirt/Top Size #3 *

Pants/Bottom Size: #3 *

Please give EXACT size for Mens need the Waist X Length

Different Shoe Sizes:

Men’s shoe sizes 6-16 Women’s shoe sizes: 4-13 Youth (7-12) shoe sizes: 3.5-7 Children (5-7 ) shoe sizes: 10.5-3 Toddlers (9mo-4 years) shoe sizes: 3.5-10 Infants (0-9mo) shoe sizes: 0-3

Shoe Department: #3 *

Shoe Size: #3 *

Please give EXACT Size

Shoe Width: #3 *

What are you in need of this Christmas? #3 *

What essentials do you need (clothes, jackets, shoes etc)? Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

What would you like to get for Christmas? #3 *

Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

4th FAMILY MEMBER'S INFORMATION

Family Member's First Name #4 *

Adult #4 (18 years and older) or Child #4? *

Adult 18+
Teenager 13-17
Child 3-12
Toddler 0-2

Please give EXACT age *

Gender #4 *

Male
Female

When inputting the sizes for clothing and shoes, please also provide the appropriate department so that we get the right size for each family member.

Clothing Department #4 *

Clothing Sizes #4 *

Shirt/Top Size #4 *

Pants/Bottom Size: #4 *

Please give EXACT size for Mens need the Waist X Length

Different Shoe Sizes:

Men’s shoe sizes 6-16 Women’s shoe sizes: 4-13 Youth (7-12) shoe sizes: 3.5-7 Children (5-7 ) shoe sizes: 10.5-3 Toddlers (9mo-4 years) shoe sizes: 3.5-10 Infants (0-9mo) shoe sizes: 0-3

Shoe Department: #4 *

Shoe Size: #4 *

Please give EXACT Size

Shoe Width: #4 *

What are you in need of this Christmas? #4 *

What essentials do you need (clothes, jackets, shoes etc)? Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

What would you like to get for Christmas? #4 *

Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

5th FAMILY MEMBER'S INFORMATION

Family Member's First Name #5 *

Adult #5 (18 years and older) or Child #5? *

Adult 18+
Teenager 13-17
Child 3-12
Toddler 0-2

Please give EXACT age *

Gender #5 *

Male
Female

When inputting the sizes for clothing and shoes, please also provide the appropriate department so that we get the right size for each family member.

Clothing Department #5 *

Clothing Sizes #5 *

Shirt/Top Size #5 *

Pants/Bottom Size: #5 *

Please give EXACT size for Mens need the Waist X Length

Different Shoe Sizes:

Men’s shoe sizes 6-16 Women’s shoe sizes: 4-13 Youth (7-12) shoe sizes: 3.5-7 Children (5-7 ) shoe sizes: 10.5-3 Toddlers (9mo-4 years) shoe sizes: 3.5-10 Infants (0-9mo) shoe sizes: 0-3

Shoe Department: #5 *

Shoe Size: #5 *

Please give EXACT Size

Shoe Width: #5 *

What are you in need of this Christmas? #5 *

What essentials do you need (clothes, jackets, shoes etc)? Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

What would you like to get for Christmas? #5 *

Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

6th FAMILY MEMBER'S INFORMATION

Family Member's First Name #6 *

Adult #6 (18 years and older) or Child #6? *

Adult 18+
Teenager 13-17
Child 3-12
Toddler 0-2

Please give EXACT age *

Gender #6 *

Male
Female

When inputting the sizes for clothing and shoes, please also provide the appropriate department so that we get the right size for each family member.

Clothing Department #6 *

Clothing Sizes #6 *

Shirt/Top Size #6 *

Pants/Bottom Size: #6 *

Please give EXACT size for Mens need the Waist X Length

Different Shoe Sizes:

Men’s shoe sizes 6-16 Women’s shoe sizes: 4-13 Youth (7-12) shoe sizes: 3.5-7 Children (5-7 ) shoe sizes: 10.5-3 Toddlers (9mo-4 years) shoe sizes: 3.5-10 Infants (0-9mo) shoe sizes: 0-3

Shoe Department: #6 *

Shoe Size: #6 *

Please give EXACT Size

Shoe Width: #6 *

What are you in need of this Christmas? #6 *

What essentials do you need (clothes, jackets, shoes etc)? Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

What would you like to get for Christmas? #6 *

Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

7th FAMILY MEMBER'S INFORMATION

Family Member's First Name #7 *

Adult #7 (18 years and older) or Child #7? *

Adult 18+
Teenager 13-17
Child 3-12
Toddler 0-2

Please give EXACT age *

Gender #7 *

Male
Female

When inputting the sizes for clothing and shoes, please also provide the appropriate department so that we get the right size for each family member.

Clothing Department #7 *

Clothing Sizes #7 *

Shirt/Top Size #7 *

Pants/Bottom Size: #7 *

Please give EXACT size for Mens need the Waist X Length

Different Shoe Sizes:

Men’s shoe sizes 6-16 Women’s shoe sizes: 4-13 Youth (7-12) shoe sizes: 3.5-7 Children (5-7 ) shoe sizes: 10.5-3 Toddlers (9mo-4 years) shoe sizes: 3.5-10 Infants (0-9mo) shoe sizes: 0-3

Shoe Department: #7 *

Shoe Size: #7 *

Please give EXACT Size

What are you in need of this Christmas? #7 *

What essentials do you need (clothes, jackets, shoes etc)? Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

What would you like to get for Christmas? #7 *

Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

8th FAMILY MEMBER'S INFORMATION

Family Member's First Name #8 *

Adult #8 (18 years and older) or Child #8? *

Adult 18+
Teenager 13-17
Child 3-12
Toddler 0-2

Please give EXACT age *

Gender #8 *

Male
Female

When inputting the sizes for clothing and shoes, please also provide the appropriate department so that we get the right size for each family member.

Clothing Department #8 *

Clothing Sizes #8 *

Shirt/Top Size #8 *

Pants/Bottom Size: #8 *

Please give EXACT size for Mens need the Waist X Length

Different Shoe Sizes:

Men’s shoe sizes 6-16 Women’s shoe sizes: 4-13 Youth (7-12) shoe sizes: 3.5-7 Children (5-7 ) shoe sizes: 10.5-3 Toddlers (9mo-4 years) shoe sizes: 3.5-10 Infants (0-9mo) shoe sizes: 0-3

Shoe Department:#8 *

Shoe Size: #8 *

Please give EXACT Size

Shoe Width: #8 *

What are you in need of this Christmas? #8 *

What essentials do you need (clothes, jackets, shoes etc)? Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

What would you like to get for Christmas? #8 *

Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

9th FAMILY MEMBER'S INFORMATION

Family Member's First Name #9 *

Adult #9 (18 years and older) or Child #9? *

Adult 18+
Teenager 13-17
Child 3-12
Toddler 0-2

Please give EXACT age *

Gender #9 *

Male
Female

When inputting the sizes for clothing and shoes, please also provide the appropriate department so that we get the right size for each family member.

Clothing Department #9 *

Clothing Sizes #9 *

Shirt/Top Size #9 *

Pants/Bottom Size: #9 *

Please give EXACT size for Mens need the Waist X Length

Different Shoe Sizes:

Men’s shoe sizes 6-16 Women’s shoe sizes: 4-13 Youth (7-12) shoe sizes: 3.5-7 Children (5-7 ) shoe sizes: 10.5-3 Toddlers (9mo-4 years) shoe sizes: 3.5-10 Infants (0-9mo) shoe sizes: 0-3

Shoe Department: #9 *

Shoe Size: #9 *

Please give EXACT Size

Shoe Width: #9 *

What are you in need of this Christmas? #9 *

What essentials do you need (clothes, jackets, shoes etc)? Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

What would you like to get for Christmas?#9 *

Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

10th FAMILY MEMBER'S INFORMATION

Family Member's First Name #10 *

Adult #10 (18 years and older) or Child #10? *

Adult 18+
Teenager 13-17
Child 3-12
Toddler 0-2

Please give EXACT age *

Gender #10 *

Male
Female

When inputting the sizes for clothing and shoes, please also provide the appropriate department so that we get the right size for each family member.

Clothing Department #10 *

Clothing Sizes #10 *

Shirt/Top Size #10 *

Pants/Bottom Size: #10 *

Please give EXACT size for Mens need the Waist X Length

Different Shoe Sizes:

Men’s shoe sizes 6-16 Women’s shoe sizes: 4-13 Youth (7-12) shoe sizes: 3.5-7 Children (5-7 ) shoe sizes: 10.5-3 Toddlers (9mo-4 years) shoe sizes: 3.5-10 Infants (0-9mo) shoe sizes: 0-3

Shoe Department: #10 *

Shoe Size: #10 *

Please give EXACT Size

Shoe Width: #10 *

What are you in need of this Christmas? #10 *

What essentials do you need (clothes, jackets, shoes etc)? Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

What would you like to get for Christmas? #10 *

Not to exceed $50.00 each gift. List a couple of items including colors if applicable. Be SPECIFIC ! Please do not put down gift cards.

Thank You for completing the 2022 Adopt-A Family Christams Intake Form

Once approved you will be contacted by one of our Team members. At that time we can address any questions/concerns.

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