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Child's Information

Child's First and Last Name

Child's Address

Child's Gender
—Please choose an option—MaleFemale

Child's Date of Birth

Child's Age

Source Information

Your First and Last Name

Your Relationship to Child
—Please choose an option—MotherFatherStepparentLegal GuardianSiblingGrandparentOther family (e.g. aunt/uncle)NeighborFriendTeacherSocial WorkerCounselor/TherapistNurse/DoctorLaw Enforcement

How did you hear about Bricks for Good?
—Please choose an option—FriendFamilyVolunteerSocial Media (Facebook, Instagram, etc.)Local NewsCommunity EventFlyer/PosterSchoolHealthcare ProviderOther

Your Email

Your Address

Your Phone Number

Parent/Guardian Information

Parent/Guardian's First and Last Name

Parent/Guardian's Email

Parent/Guardian's Phone Number

What is the parent or guardian's highest level of education?
—Please choose an option—No formal educationDidn't complete high schoolHigh school diploma or equivalent (GED)Technical or occupational certificateSome college coursework completedAssociate's degreeBachelor's degreeMaster's degreeDoctorate degree

What is the parent or guardian's marital status?
—Please choose an option—Single (never married)MarriedSeparatedDivorcedWidowed

Child's Details

What school does the child attend?

What school grade is the child?
—Please choose an option—Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade

What grades does the child generally receive in school?
Mostly A'sMostly B'sMostly C'sMostly D'sMostly F'sNot enrolled in school

Please consider child for:
Birthday LEGO GiftChristmas LEGO GiftBirthday + Christmas LEGO GiftOne-time LEGO GiftEducation Scholarship/Grant

Child's Primary Housing Status
—Please choose an option—With motherWith fatherWith mother and father (Same household)With mother and father (Shared or Partial Custody)With grandparentsWith other familyWith legal guardianAt boarding schoolIncarcerated (Juvenile Detention)Hospitalized (Long-term Stay)

Child's Household Annual Income
—Please choose an option—<$10,000$10,000 - $25,000$25,000 - $35,000$35,000 - $45,000$45,000 - $55,000$55,000 - $65,000$65,000 - $75,000$85,000 - $100,000>$100,000

Child's Household Family Size
2345678+

Please select any government assistance the child's household is currently receiving.
SNAP/Food StampsTANF (Temporary Assistance)Cash AssistanceHeating Assistance/LIHEAPHome Water Help/LIHWAPHousing Assistance/Section 8WICUnemploymentReduced/Low-income LunchMedical AssistanceOtherNone

Does the family identify with any particular religion?
ChristianCatholicJewishBuddhistAtheistAgnosticSpiritualOtherNone

What is the child's race?
White/CaucasianBlack/African-AmericanHispanic/Latin-AmericanAsian-AmericanNative AmericanMixedOther

Is the child a U.S. citizen?
YesNo

Is the child currently safe, fed, clothed, and otherwise cared for?
YesNo

If NO, please provide details:

Is the child a victim of abuse?
Yes, child was abused in the past.No, child was never abused.

If YES, please provide the following information:
WHO was involved (full name), WHAT happened, WHEN did the incident occur, and WHERE did it take place?

Is the child currently receiving any mental health treatment (therapy, counseling, or medication)?
YesNo

If YES, please provide details:

Does the child have any intellectual or physical disabilities?
YesNo

If YES, please provide details:

Does the child currently own any LEGO sets?
YesNo

What are some of the child's favorite LEGO themes?
ArchitectureArtAvatarBatmanBrick SketchesBrickHeadzCityClassicCreator 3in1Creator ExpertDCDisneyDOTSDUPLODreamzFriendsGabby's DollhouseHarry PotterIconsIdeasIndiana JonesJurassic WorldLord of the RingsMarvelMINDSTORMSMinecraftMinifiguresMinionsMonkie KidNINJAGOPowered UPSonic the HedgehogSpeed ChampionsSpider-ManStar WarsSuper MarioTechnicVIDIYO

What are some fun facts you can share about the child?

Is the child able to attend Santa's Visit on Wednesday, December 18, 2024 at 6pm in Harrisburg to receive their 2024 Christmas gift? (Details to follow)
YesNo

Child's Photo (required)
Please include a color photo that shows the child by themselves in clear view, fully clothed, and forward-facing. Generally, a recent school picture day photo works best unless you have a separate favorite to share.

How can we serve you?

Attachments (optional)
Please upload any additional documents here, such as the child's report card and 500+ word essay if applying for an educational scholarship or grant. If you'd prefer, you may provide these documents later.

By submitting this form, you consent to having a representative contact you via phone, text message, and/or email. All information submitted is regarded as strictly confidential. With that in mind, the staff at Bricks for Good are mandated reporters. We are required by law and moral imperative to report any suspected child abuse to the PA Department of Human Services. Any inappropriate content submitted will be immediately forwarded to authorities.