Family Name

First Name of Child/Adult Donating

Address

City

State

AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Zip Code

Is it a one Time Donation?

Yes   No

Telephone

Please specify type of donation (clothes, household items, bedding, maternity, bedding, books, toys, other)

Date you prefer donation to be picked up

Time

Do you wish to be present?

Yes   No

Do you want nation children to keep you on the list of donors?

Yes Call Periodically   No Do Not Call

Would you like to be updated on nation children’s future programs and campaigns for children?

Yes   No

Do you want your children to be a part of nation children’s programs?
(i.e child craft & trade exhibition, concerts and fun fairs etc….)

Yes   No

If yes please provide name/s of child/children

Would you or any family member like to volunteer for nation children charity programs

Yes   No