info@gspcharity.com
(441) 296-0016
Monday - Friday: 8.00am - 5:00pm
About
The Gina Spence Program
Our Team
Our Partners
Our Impact
How You Can Help
Volunteer
Fundraising
What We Do
Bermuda’s Grief & Loss Awareness Day
Community Outreach
Each One Reach One Back To School Program
Christmas Gift Of Giving Program
Grief and Loss
Healing Hearts Program
Champions Program
Visionary Venture Program
Donate
Media
Events
News
Contact Us
Send a message
Employment Opportunities
About
The Gina Spence Program
Our Team
Our Partners
Our Impact
How You Can Help
Volunteer
Fundraising
What We Do
Bermuda’s Grief & Loss Awareness Day
Community Outreach
Each One Reach One Back To School Program
Christmas Gift Of Giving Program
Grief and Loss
Healing Hearts Program
Champions Program
Visionary Venture Program
Donate
Media
Events
News
Contact Us
Send a message
Employment Opportunities
Any questions ?
Phone (441) 296-0016
$
0.00
0
Cart
The form is not published.
Gift of Giving Application Form
Step
1
of
5
– Consent to share information
0%
Unique ID
This field is hidden when viewing the form
Applicant Consent
Bringing Holiday Cheer
As we enter the Christmas season, we are reminded of the joy that comes from giving and supporting those around us. Our goal is to help make this season a little brighter for families and individuals in need, bringing hope and holiday cheer to our community.
Why We Are Asking for Additional Information
To better align our support with the needs of the community, we now collect detailed information on household income, financial assistance, and experiences with grief and loss. This helps us ensure that our resources are reaching the families who need them the most.
Consent to Share Information
Please insert your initials as agreement to share your information. Your information will not be publicized and is only kept for data purposes to ensure our resources reach the families who need them the most.
Initials:
(Required)
Applicant Information
Full Name of Parent/Guardian:
(Required)
First
Last
Phone Number:
(Required)
Email Address:
(Required)
Home Address
(Required)
Street Address
Parish
Zip Code:
Type of Support Requested
(Required)
Register for a Healthy Food Hamper
Register for a Pharmaceutical Gift Card for Senior
How many people in the household?
(Required)
Please enter a number from
0
to
10
.
Adults
(Required)
Please enter a number from
0
to
10
.
Children
(Required)
Please enter a number from
0
to
10
.
Full Name of Senior:
(Required)
First
Last
Phone Number:
(Required)
Home Address of Senior
(Required)
Street Address
Parish
Zip Code:
Color of House
(Required)
Does the household have a dog?
(Required)
Yes
No
How many children?
(Required)
1
2
3
4
5
Please fill in the information below for each child for up to 5 children
Child 1
Full Name:
(Required)
First
Last
Age Category:
(Required)
1-3 years
4-6 years
7-9 years
10-11 years
Gender
(Required)
Male
Female
Child 2
Full Name:
(Required)
First
Last
Age Category:
(Required)
1-3 years
4-6 years
7-9 years
10-11 years
Gender
(Required)
Male
Female
Child 3
Full Name:
(Required)
First
Last
Age Category:
(Required)
1-3 years
4-6 years
7-9 years
10-11 years
Gender
(Required)
Male
Female
Child 4
Full Name:
(Required)
First
Last
Age Category:
(Required)
1-3 years
4-6 years
7-9 years
10-11 years
Gender
(Required)
Male
Female
Child 5
Full Name:
(Required)
First
Last
Age Category:
(Required)
1-3 years
4-6 years
7-9 years
10-11 years
Gender
(Required)
Male
Female
Has your family experienced a recent loss or grief of a person who lived in your household?
(Required)
Yes
No
If yes, please select the type of loss:
(Required)
Death of a parent who lived in my household
Death of a sibling who lived in my household
Death of a grandparent who lived in my household
Death of a close relative who lived in my household
Job loss of myself or a member of my household
Family separation or divorce
Incarceration of a family member who lived in my household
Serious illness in the family of a member who lived in my household
Other
If other, please explain:
(Required)
Household Income:
(Required)
Under $45,000
$45,000 – $55,000
$55,000 – $75,000
$75,000 – 95,000
Over $95,000
How many working people are in your household?
(Required)
Less than 1
Less than 2
Less than 3
More than 3
Are you currently receiving any type of financial assistance?
(Required)
Yes
No
If yes, please specify the type of assistance:
(Required)
Government Financial Assistance Department
Family Centre
Big Brothers Big Sisters
PALS Bermuda
The Coalition for the Protection of Children
Bermuda Cancer and Health
Other:
If other, please explain:
(Required)
