EASTER BASKET RECIPIENT – Palatine Township

You must be a Palatine Township resident. Only children ages 1 - 10 years old are eligible.

You must enter a new form for each child.

The basket(s) must be picked up by 9:00 AM and 3:30 PM on April 17, 2019.

All baskets must be picked up by 3:30 PM on April 17, 2019. They will not be held for late pick-up.

*Note* If you do not show up to pick up your basket, you will not be eligible to participate in any Township sponsored outreach programs for one year. Confirmation letters will be mailed by April 5 and will include details about Easter Basket pick-up procedures. If you do not receive your letter by April 12 you must contact the Township at 847-358-6700.

AN APPLICATION SHOULD BE COMPLETED FOR EACH CHILD INDIVIDUALLY.

Easter baskets are for your children who live at home ages 1 - 10 years. Children must be 10 years old on or before April 16. only.

General Assistance Case Number

If you participate in Township Programs, please provide your Case Number, found on your Food Pantry card or correspondence.

Parent Guardian #1 Name*

First Last

Parent Guardian #2 Name

First Last

Address*

Street Address Address Line 2 City ZIP Code

Phone*

Email*

Enter Email Confirm Email

Child's Name*

First Last

Child's Age*

Please enter a number from 0 to 11.

Gender*

Male
Female

Do you receive additional assistance, other than Palatine Township?*

Yes
No

AGENCY - Select from the list below.

I confirm my consent.*

I agree.

I am aware that participating in other organizations' Easter Programs is strictly prohibited. Agencies will cross reference lists, and if I am enrolled in more than one program I will be removed from Palatine Township Programs for one year. I hereby authorize Palatine Township to use my photo in Township materials including newsletters, the website and to release my name to volunteers/churches, and other organizations. I understand that my name will not be released to soliciting organizations. By clicking "I confirm my consent " above, it serves as my signature and indicates that i agree with the terms of this program.

2019 EASTER BASKET RECIPIENT

2019 Easter Basket Recipient Form