Name of person completing this application *

First Name

Last Name

Phone *

(###)

###

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Caregiver Name

First Name

Last Name

Caregiver Phone

(###)

###

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Address where gift should be mailed

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Case Worker Name (If applicable)

First Name

Last Name

Case Worker Phone

(###)

###

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Child's Name (Child MUST currently be in foster or formal kinship care) *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

By enrolling this child in Made to Celebrate! *

I agree to inform Dwell if the child I am registering is removed from my physical custody before their birthday.

I understand that the gift the child receives from Dwell’s Made To Celebrate! program belongs to the child and stays with the child if/when the child leaves my home for any reason.

I attest that the information in this application is true to the best of my knowledge and belief.

I confirm that the child I am registering with Dwell in the Made To Celebrate! program is either in my physical custody (I am the foster or kinship parent) or is a child on my caseload (I am the child’s caseworker).

I hereby request to enroll the above child (who is in foster or kinship care) in Dwell’s Made to Celebrate! Program. My electronic signature is proof of acknowledging I have read and understood the above information. By completing and signing this application, I understand that Made to Celebrate! is provided by Dwell, a nonprofit organization, at no cost and I will not take advantage of this program.