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Holiday Giving 2021 - Wish List
DUE DATE: NOVEMBER 5, 2021
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Parent Name
*
Your answer
Address
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Your answer
Telephone
*
Your answer
Email
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Your answer
Marital Status
Single
Married
Separated
Divorced
Widowed
Clear selection
I am the Parent/Guardian of all children listed on this form
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Yes
No
All the children on this form are residents of Old Lyme or Lyme
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Yes
No
I would like information on the following programs
Food pantries in my area
SNAP (food stamps)
Thanksgiving Food Drive (at LYSB)
Energy Assistance
WIC (Women/Infant/Children)
Warm the Children
School Meals (free/reduced)
HUSKY Insurance
Total of people in household
Your answer
Total number of adults female
Your answer
Total number of adults male
Your answer
Total number of children
Your answer
Number of veterans in your home
Your answer
Number of elderly (65+) in your home
Your answer
How do you heat your home
Your answer
Has your family been affected financially by COVID19? If yes, how? If no, skip.
Your answer
Are you in need of diapers? If yes, what size
Your answer
CHILD #1 full name
*
Your answer
CHILD #1 Date of Birth
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MM
/
DD
/
YYYY
CHILD #1 Age
*
Your answer
CHILD #1 Grade and name of school
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Your answer
CHILD #1 Gender
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Male
Female
CHILD #1 GIFTS Wish List: (Each child will receive two or three items. Please list up to three items your child would like. Tell us about your child's likes/dislikes, clothing sizes, favorites, colors, etc)
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Your answer
CHILD #1 GIFT CARDS Wish List: (gift cards requested for child)
*
Your answer
Finished?
No, I have additional children to enter
Yes, I'm done and ready to submit.
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