de l'Epee Deaf Center- Holiday Basket 2022

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You only need to complete this application once for both Christmas and Thanksgiving baskets
Deadline to receive Thanksgiving & Christmas Basket: November 11th
After November 5th you can only receive a Christmas Basket.
Deadline for Christmas ONLY Basket: December 9th

You MUST be 18 years or older to complete this form. Your child OR yourself must be Deaf or Hard of Hearing. If your child is Deaf/Hard of Hearing and they are 18 or older, they must be the ones to complete the application.

First and Last Name

Are you Deaf?

Yes

Clear selection

If you are not Deaf do you have a child(ren) under the age of 18 living in your house that is Deaf?

Yes

Clear selection

Address, City, State, Zip

Phone Number

What type of phone did you list above?

Hearing Phone

Text

Drivers License or Social Security number

What number did you list above?

SS #

Driver's License #

Clear selection

Clear form

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