The purpose of the Adopt-A-Child Christmas Program is to provide gifts and warm clothing to needy children who are from birth to 12 years of age.  Before completing this form, you should understand that the organization is asking as a minimum gift a warm winter jacket or coat, one / two winter outfits that can be worn to school and/or on special occasions and at least one toy or game for their age group.  Other miscellaneous gifts or clothing items are optional.

I would like to be an Adopting Parent for the year			2006 2007 2008 2009 2010
First Name: Middle Initial:		Last:
Work Phone: (###)-###-####
Address:		City:
State:	- Select - 1 2 3 4 5 6 7 8 9 10	Zip:
Home Phone: (###)-###-####
Group Name (If Adopting as a Group):
Referred by: - Select - 1 2 3 4 5 6 7 8 9 10		Name:
Phone No.: (###)-###-####
I wish to adopt			Boy(s)	0 1 2 3 4 5 6 7 8 9 10
			Girl(s)	0 1 2 3 4 5 6 7 8 9 10
			Family of	0 1 2 3 4 5 6 7 8 9 10
Did you participate last year?			Yes No
If yes and you wish to be matched with the same child(ren) or family, please indicate the name(s) below:		1
		2
		3
		4
Will someone be in attendance to present your gifts?			Yes No
**Thank You For Brighten a Child's Christmas** by Becoming an Adoptive Parent