PROJECT ELF - I NEED HELP FOR CHRISTMAS

(Individual request)

Return to The Dane Foundation before November 15, 2017

The Dane Foundation provides for the “unique” needs of individuals with developmental or physical disabilities. (We serve individuals with developmental and physical disabilities; we are NOT an organization serving those with mental illnesses or drug/alcohol addiction.) At this time, the Foundation’s focus is on providing personal items not typically covered by other organizations, insurance, or supports. Examples: household items, paper products, clothing, holiday toys, adaptive furniture and equipment, personal assistance (example is a senior citizen that needs assistance with home maintenance), etc. WE DO NOT PROVIDE CASH OR GIFT CARDS. WE DO NOT PAY UTILITY BILLS, MORTGAGE PAYMENTS, OR OTHER BILLS. We will not deliver items/donations to you; you or someone you designate will have to pick up the gifts at our offices in Cuyahoga Falls on the assigned date in December.

Ø  Date of request:

Ø  Name of person making request:

Ø  Agency or organization (if appropriate)

Ø  Your Phone: Your Email:

Ø  How did you hear about The Dane Foundation?

Ø  Please tell us how the individual qualifies for our services? Please describe nature/type & onset of disability:

Ø  Has The Dane Foundation served this individual in the past? When?

Ø  What other organizations will be serving this individual for Christmas?

Please complete the below Individual’s Request for Holiday Help:

o  Name of person who needs holiday help:

o  Age:

o  Type of residence (circle): own home/apt group home family home

o  City of residence:

o  Best way to contact (circle ) phone email text

Phone: Email:

____ Yes, I need general household items (paper towels, toilet paper, cleaning products, laundry) Please describe:

____ Yes, I need toiletry items (toothpaste, shampoo, deodorant, soap, cologne, shaving items) Please describe:

Ø  Wish List For Individual (no more than 5 items per person in addition to above needs) :

Item Requested Size (if clothing, shoe, coat, hat, glove, sheets, etc. related)

1.

2.

3.

4.

5.

My Christmas wish… (toy or other item that is a “true” Christmas gift not a “need”