Christmas Wish List Template

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Christmas Wish List
ID#
Would you like to have your Christmas Wish List put on the web so people in the community could read a
little bit about you and send you a note and/or a gift?
Please understand there is no assurance that you will receive what you ask for,
but every effort will be made to provide as much as possible.
First Name________________Middle Initial____Last initial:____ Birthdate:_____________
Gender: __M/ __F Where would you like to pick up your gift?________________________
Name of interviewer (if filled out by someone else): ________________________________
Tell Us Something About Yourself--Share only what you feel comfortable with telling others
Answer these questions or
_______________________________________________________
share whatever you’d like to
_______________________________________________________
say.
_______________________________________________________
_______________________________________________________
Where are you from
_______________________________________________________
originally?
_______________________________________________________
_______________________________________________________
How long have you been in
_______________________________________________________
the area?
_______________________________________________________
_______________________________________________________
What brought you here?
_______________________________________________________
_______________________________________________________
What encourages you
_______________________________________________________
most?
_______________________________________________________
_______________________________________________________
What interests do you
_______________________________________________________
have?
_______________________________________________________
_______________________________________________________
What’s your biggest
_______________________________________________________
challenge? (e.g. food,
_______________________________________________________
keeping warm, security)
_______________________________________________________
_______________________________________________________
What would you like for
_______________________________________________________
others to pray about for
_______________________________________________________
you?
_______________________________________________________
_______________________________________________________
What would you like others
_______________________________________________________
to know to help them
_____________________________________________________________
understand your situation?
_____________________________________________________________
What do you want for Christmas? Choose ______ items:
Warm footwear- size____gender____
backpack
socks
underwear, especially thermal-
size_____ gender____
blanket
phonecard
hat, gloves & scarf
transportation tickets -
clothing item___________________
what kind?_____ where?________
size____ colour prefer.__________
other items:___________________
warm winter coat-
_____________________________
size:____ gender_____
Release of Confidential Information
I, _______________________________ give permission to The _____________________,
to release or obtain, verbally or in writing the above information:
This information may be obtained by, or released to the Christmas Wish List to be posted
on the web. This consent expires automatically upon discharge from the above agency.
Date: ____________________________ Signature: _______________________
Witness: _________________________ Position: ________________________
The Christmas Wish List is supported by members of churches of Christ in ________(city).

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