This form is for:  Victims of Hurricane Katrina ONLY - 2010

THIS FORM IS NOT FOR ANYONE WHO WANTS A FREE HANDOUT OR TO TAKE ADVANTAGE OF THOSE WITH A PURE HEART.

Only your name and a small portion of information about you and your needs will be listed.

Please read disclaimer at bottom.

YOU MUST REGISTER TO BE ADOPTED EVERY 12 MONTHS WITH AN UPDATE OF YOUR PROGRESS AND YOUR EFFORTS.  PRINT A COPY OF THIS FORM FOR YOUR RECORDS -
WHEN YOU ARE POSTED ON THE ANGEL TREE -
PLEASE KEEP UP WITH YOUR REGISTRATION NUMBER.

Date of this entry:
*** REQUIRED ***		   (REQUIRED)
Name of person completing this form:
*** REQUIRED ***		   Relationship to Victim/Needy
 (REQUIRED)                                                                     If other, specify 
Your contact telephone number: (REQUIRED)
Number of People in your family: (REQUIRED)
Parents' Ages: Mother:    Father:    
Children's Ages (girls):   (example:  3,7,9)
Children's Ages (boys):     (example:  3,7,9)
Other Family Member's Age:
Please describe your disaster experience or where you are in your time of need:
*** REQUIRED ***

PLEASE DESCRIBE YOUR CURRENT LIVING CONDITIONS - where you are in your recovery/rebuilding.

(REQUIRED)
What kind of items are you most in need of? (example: clothing, linens, cookware, food, general household items, school clothes, medical needs, cleaning supplies, yard tools, be specific)
*** REQUIRED ***

(REQUIRED)
Former Street Address:
(if you have lost your home)
*** REQUIRED ***		 (REQUIRED)
City: (REQUIRED)
State:  (REQUIRED)
 Zip:
Where are you staying now?
*** REQUIRED ***
Location? 
If Other, specify (example: hotel, military base etc.)
Name of Victim/Needy:
*** REQUIRED ***
Name:  
Age: Birthdate: Gender:
Shirt
Size:		 Skirt/Pant
Size:		 Favorite
Color:
Special Needs:
(diabetic, medical conditions etc.)
Interests/Hobbies:
Please list all individuals in your IMMEDIATE family:

*** Note:  Please fill out this form in detail.  This will help the person/family/group know exactly what items to send you. ***
Spouse Name:  
Age: Birthdate: Gender:
Shirt
Size:		 Skirt/Pant
Size:		 Favorite
Color:
Special Needs:
(diabetic, medical conditions etc.)
Interests/Hobbies:
Child #1 Name:  
Age: Birthdate: Gender:
Shirt
Size:		 Skirt/Pant
Size:		 Favorite
Color:
Special Needs:
(diabetic, medical conditions etc.)
Interests/Hobbies:
Child #2 Name:  
Age: Birthdate: Gender:
Shirt
Size:		 Skirt/Pant
Size:		 Favorite
Color:
Special Needs:
(diabetic, medical conditions etc.)
Interests/Hobbies:
Child #3 Name:  
Age: Birthdate: Gender:
Shirt
Size:		 Skirt/Pant
Size:		 Favorite
Color:
Special Needs:
(diabetic, medical conditions etc.)
Interests/Hobbies:
Child #4 Name:  
Age: Birthdate: Gender:
Shirt
Size:		 Skirt/Pant
Size:		 Favorite
Color:
Special Needs:
(diabetic, medical conditions etc.)
Interests/Hobbies:
Child #5 Name:  
Age: Birthdate: Gender:
Shirt
Size:		 Skirt/Pant
Size:		 Favorite
Color:
Special Needs:
(diabetic, medical conditions etc.)
Interests/Hobbies:
Child #6 Name:  
Age: Birthdate: Gender:
Shirt
Size:		 Skirt/Pant
Size:		 Favorite
Color:
Special Needs:
(diabetic, medical conditions etc.)
Interests/Hobbies:
Child #7 Name:  
Age: Birthdate: Gender:
Shirt
Size:		 Skirt/Pant
Size:		 Favorite
Color:
Special Needs:
(diabetic, medical conditions etc.)
Interests/Hobbies:
Child #8 Name:  
Age: Birthdate: Gender:
Shirt
Size:		 Skirt/Pant
Size:		 Favorite
Color:
Special Needs:
(diabetic, medical conditions etc.)
Interests/Hobbies:
OTHER Immediate Members (living with you)
Age: Birthdate: Gender:
Shirt
Size:		 Skirt/Pant
Size:		 Favorite
Color:
Special Needs:
(diabetic, medical conditions etc.)
Interests/Hobbies:
How kin?
OTHER Immediate Members (living with you)
Age: Birthdate: Gender:
Shirt
Size:		 Skirt/Pant
Size:		 Favorite
Color:
Special Needs:
(diabetic, medical conditions etc.)
Interests/Hobbies:
How kin?
How can you be contacted?
Phone of your current location:
*** REQUIRED ***
Address where you can be contacted:
*** REQUIRED ***		 Street: 

City:    State:    Zip: 

Cell Phone:
Email Address:
*** REQUIRED *** 
Additional Comments:
If you have signed up for the Hurricane Katrina Angel Tree in the past - what is your registration number?

If you would like to include a picture of your family or your disaster in your post
please email it to katrina@katrina.com

 

Disclaimer:  All information provided in this web site is for informational purposes only.  This is not a government site.  No contract, either express or implied, is created between the owner/operator of this site and the public.  Every reasonable effort has been made to provide accurate information; however, the information in this site is not warranted or guaranteed in any way.  The owner/operator of this site shall in no way be deemed responsible for any injury suffered, either directly or indirectly, from the use of this site, or the information contained herein.
Personal information collected by victims or adopters are not sold or given to any other entity.

1998 - 2010.  All rights reserved.