Thirteen's 13 Families Submission Form

First name

Last name

Phone

Email

What is your social media handle?

How many people in your family?

Ages of Children

Are there any special needs in the family? (e.g., physical educational, medical)

What is your household income?

Under $25,000

$25.000 to $50,000

$50,000 to $75,000

Over $75,000

What challenges are you currently facing? (e.g., financial hardship, health issues, job loss, etc)

What specific needs do you have this holiday season? (e.g., toys for children, clothing, food, etc.)

Are there any particular items that would bring joy to your family this holiday season?

Is there anything else you would like us to know about your family?

Do you consent to have your information shared with our partners for the purpose of this program?

Yes

No

Confidentiality Statement: Your privacy is important to us. The information you provide in this survey will be kept strictly confidential and will only be used for the purpose of assessing needs. We will not share your personal information with any third parties without your consent. All responses will be anonymized in any reports or publications. Thank you for your participation and helping us serve our community better.