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A Season of Giving Decatur
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Senior Application
Step
1
of
3
33%
Company
This field is for validation purposes and should be left unchanged.
Sponsor ID
Email
Delivery Date
Month
Day
Year
Received By
Social Worker Information
Social Worker Email
Social Worker Name
First
Last
Resident Information
Name
(Required)
First
Last
Gender
(Required)
Female
Male
Age
(Required)
Please enter a number from
60
to
110
.
Living Situation
(Required)
Alone
With Family
With live-in caretaker
Home Location
(Required)
Clairemont Oaks
Oliver House
Park Trace
Phillips Tower
Spring Point
Swanton Heights
Trinity Walk
Address
Street Address
Apartment Number
City
ZIP / Postal Code
Phone
(Required)
Alternate Contact
Alternate Contact Name
(Required)
First
Last
Alternate Contact Phone
(Required)
Alternate Contact Email
Enter Email
Confirm Email
Wish List
Height
In feet and inches
Weight
In pounds
How Active are you?
(Required)
Active (walks, drives, out of home frequently)
Limited activity
Little to no mobility
Hobbies
(Required)
Check all that apply
Church
Cooking
Day Trips
Gardening
Housework
Knitting
Music
Reading
Sewing
TV
Other (explain in the Other Information field)
Health Issues
(Required)
Diabetes
Dialysis
Hearing Impaired
Recent Illness/Hospitalization
Use a walker
Vision Problems
Wheelchair bound
Other
None
Health Issues
Clothing Department
Men's
Men's Big & Tall
Women's
Women's Plus
Women's Petite
Shirt Size
(Required)
Pants Size
(Required)
Dress Size
Other Information
Wish List Items
IMPORTANT!!
Please select
3-4 TOTAL clothing items
prioritizing the things you need.
Donors are asked to spend
approximately $150 per person TOTAL
. Select items you would like from the list below. Add color, brand, fragrance and other preferences in the boxes below the checkboxes. To request something that is not listed below, please use the "Other Requests" area.
Women's Clothing
Blouse
Button down collared shirt
Cardigan
Coat (heavy)
Dress
Hoodie (hooded sweatshirt)
House coat
House shoes / slippers
Jacket (lightweight)
Jeans
Nightgown
Pajamas
Robe
Shoes
Socks
Sweat pants
Sweat shirt
Sweater
Tank tops
Turtleneck
T Shirt
Track suit/sweat suit
Underwear/panties
Men's Clothing
Boxers
Briefs
Coat (heavy)
Dress slacks/khakis
Gloves
Hoodie (hooded sweatshirt)
House shoes / slippers
Jacket (lightweight)
Jeans
Polo shirt
Pajamas
Robe
Shoes
Socks
Sweat shirt
Sweater
Clothing color/style/brand
Toiletries
Air freshener
Body wash
Cologne
Lotion
Perfume
Soap
Toothpaste
Cleaning/Personal Care
Batteries
Cleaning supplies
Decatur trash bags - blue
Decatur trash bags - green
Decatur trash bags - yellow
Dish soap
Kleenex
Laundry detergent
Paper towels
Toilet paper
Toiletries Scent/Flavor/Brand
Cleaning/Personal Care Scent/Flavor/Brand
Small Appliances
Air fryer
Air purifier
Blender
Coffee maker
Crockpot
Electric blanket
Electric can opener
Electric heated socks
Electric razor/shaver
Fan
Foot massager
Heating pad
Juicer
Microwave
Portable CD player
Portable heater
Portable radio
Toaster
Toaster oven
Household Items
Bath mat / contour set
Bath stool
Blanket
Comforter
Cutting boards
Dish towels
Flashlight set
Food storage containers
Glassware / cups set
Grocery cart (wheeled/folding)
Handkerchiefs
Mattress cover/protector
Mop / Swiffer
Pillows
Pots and pans set
Sheet set
Towels
TV / eating tray
Other Items
Bible
Candy / chocolate
Compression socks
Depends / incontinence underwear
Ensure / meal replacement
Grocery Gift Card (indicate store in Other Requests area)
Jewelry - earrings (pierced)
Purse
Puzzle
Puzzle book
Snacks
Stamps
Umbrella
Watch
Word search book
Small Appliances Style/Brand
Household Items Style/Brand/Color
Other Items Style/Brand/Color
Other requests
Is there anything else you'd like (NOT LISTED ABOVE) or anymore information you can provide us on what you have requested?
Senior ID
Preparer Signature
I understand that this application is for assistance only, not a promise of aid. I understand that I must follow the ASOG/Christmas Decatur guidelines in regard to this application. I understand that incomplete applications will not be considered.
Your Name
Your Name
Your Name
Your Name
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