Name *

PLESAE ENTER YOUR FULL NAME AS IT APPEARS ON YOUR VALID ID

First Name

Last Name

Current Address *

YOUR ADDRESS MUST MATCH YOUR VALID ID, LEASE OR MORTGAGE, AND UTILITY BILLS. NO EXCEPTIONS. IF YOU ARE DISPLACED WE NEED TO VERIFY BY OTHER MEANS.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Best Phone Number *

PLEASE USE A NUMBER WHERE YOU CAN BE REACHED SHOULD WE NEED TO CALL OR TEXT YOU

(###)

###

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HELP US-HELP YOU *

All of our programs are self-funded, and we do not receive government assistance or grants. We're mothers just like you, and many of us have faced similar challenges. As a result, our holiday assistance program requires those who qualify to complete a minimum of 2 hours of volunteer work to show appreciation before distribution days. We have several projects over the next two weeks that we need assistance with. Please select the event you can commit to helping us with. Your support is greatly appreciated.

DONATE BETWEEN NOVEMBER 1ST TO NOVEMBER 29TH WRAPPING PAPER, TAPE, CHRISTMAS LIGHTS, GARLANDS, DECORATIONS, ETC.

DONATE CANDY FOR OUR TRUNK OR TREAT BY OCTOBER 18

HOST A TRUNK AT OUR TRUNK OR TREAT ON OCTOBER 26 FROM 4-7PM

HOW MANY CHILDREN DO YOU HAVE BETWEEN 0-12 YEARS OLD? *

PLEASE PUT 0 IF YOU DO NOT HAVE CHILDREN. YOU MUST HAVE A BIRTH CERTIFICATE FOR EACH CHILD YOU LIST.

0

1

2

3

4

5

CHILD'S NAME & BIRTHDAY *

PLEASE PUT YOUR CHILD'S NAME AND BIRTHDATE AS SHOWN ON THEIR BIRTH CERTIFICATE.

First Name

Last Name

CHILD'S NAME & BIRTHDAY

PLEASE PUT YOUR CHILD'S NAME AND BIRTHDATE AS SHOWN ON THEIR BIRTH CERTIFICATE. IF YOU ONLY HAVE ONE CHILD PUT N/A

First Name

Last Name

CHILD'S NAME & BIRTHDATE *

PLEASE PUT YOUR CHILD'S NAME AND BIRTHDATE AS SHOWN ON THEIR BIRTH CERTIFICATE. IF YOU ONLY HAVE ONE CHILD PUT N/A

First Name

Last Name

CHILD'S NAME & BIRTHDATE

PLEASE PUT YOUR CHILD'S NAME AND BIRTHDATE AS SHOWN ON THEIR BIRTH CERTIFICATE. IF YOU ONLY HAVE ONE CHILD PUT N/A

First Name

Last Name

CHILD'S NAME & BIRTHDAY *

PLEASE PUT YOUR CHILD'S NAME AND BIRTHDATE AS SHOWN ON THEIR BIRTH CERTIFICATE. IF YOU ONLY HAVE ONE CHILD PUT N/A

First Name

Last Name

I agree *

I understand that participating in other organizations' programs is strictly prohibited. Agencies will cross-reference lists, and if I am enrolled in more than one program, I will be disqualified from BCA Hub's programs for one year. I acknowledge that to receive assistance from the BCA Hub, I must volunteer a minimum of 2 hours at any BCA Hub event or at the Clothes Closet. I hereby grant authorization to the BCA Hub to use my photo in social materials, including newsletters and the website, and to release my name to volunteers, churches, and other organizations. I understand that my name will not be released to soliciting organizations. By clicking this checkbox, I acknowledge that this serves as my signature and indicates my agreement with the terms of this program.

I have read and I agree with the terms of this program.*