CUSTOMER VALIDATION QUESTIONS

1. Which benefits are you currently receiving? Please note if you are not receiving any of these benefits, you do not qualify for the Adopt-A-Family program. The information entered will be verified.
(¿Qué beneficios está recibiendo actualmente? Tenga en cuenta que si no recibe ninguno de estos beneficios, no califica para el programa Adopt-A-Family. La información ingresada será verificada.) Value Required

2. At which DPSS office is your case located? Please note if you do not have a case open then you do not qualify for the Adopt-A-Family program. The information entered will be verified.
(¿En qué oficina del DPSS se encuentra su caso? Tenga en cuenta que si no tiene un caso abierto, entonces no califica para el programa Adopt-A-Family. La información ingresada será verificada.) Value Required

BASIC INFORMATION OF CUSTOMER

Please ensure all information is correct and is the most up-to-date information.

First Name
(Primer Nombre) Value Required

Last Name
(Apellido) Value Required

Date of Birth Value Required

Expected format: MM/DD/YYYY
Date of Birth must be in the format of MM/DD/YYYY

Case Number
(Número de Caso) Value Required

Your 7-digit case number can be found on your Medi-Cal or EBT benefits card below your card number and name. Case numbers are a mixture of letters and number (Ex: B2YZW85).

Current Address
(Direccion Actual) Value Required

City
(Ciudad) Value Required

State
(Estado) Value Required

CA

Zip Code
(Código Postal) Value Required

Mailing Address
(if different than above)
(Dirección de Envio) Value Required

City
(Ciudad) Value Required

State
(Estado) Value Required

CA

Zip Code
(Código Postal) Value Required

Telephone Number
(Número de Teléfono) Value Required

Alternate Telephone Number
(Número de Teléfono Alternativo) Value Required

Email
(Dirección de correo Electrónico) Value Required

Email communication will be used to provide a confirmation of receipt and may also be used by sponsors or DPSS staff to contact you if additional information is needed regarding your application.

Preferred Language:
(Idioma Preferido) Value Required

Ethnicity:
(Etnia) Value Required

DESCRIPTIVE SUMMARY OF FAMILY/LIVING SITUATION

Text 1

REQUIRED: Please list any hardships that will offer a better understanding of difficulties you or your family is currently or has recently faced. Please be as specific as possible. Your descriptive story will assist your sponsor so that they may more effectively understand your current situation. Provide any details you feel comfortable sharing. NOTE: Your entire application will be shared with your sponsor.

20 words minimum

FAMILY WISH LISTS Collection

Text 1

REQUIRED: Please add a wish list for each family member within your DPSS case by clicking on the blue colored button below. As you add each family member, they will be listed below. Once you see all your family members listed, you can move on to the next section. Your application may be deemed ineligible if there are individuals listed that are not on your case.

Text 1

Click Here to Add a Wish List for Each Family Member

CUSTOMER SIGNATURE

PHOTO CONSENT

Radio 1

Please note, in order to maximize those benefitting from the Adopt-A-Family Program, sponsorship is only once during the span of that individual or family's case.

I am aware that sponsorship is NOT guaranteed.

I agree to not request inappropriate items including items over $150.00

I agree to not harass sponsors or share sponsor information. I acknowledge that inappropriate behavior or a lack of requested communication with the sponsor or program staff can be subject to disqualification.

I confirm that everything on the application is true to the best of my knowledge.

I confirm that I have created a Wish List for each family member, including myself (Each family member should be listed above).