Blessing Application

Case Number

B-10-001046

Please write this case number down and keep it for your records.

Orphanage Information

Orphanage Name	*
Country	*
Street Address	*
City	*
State	*
Postal Code	*
Director's Name	*
Director's Phone	*
Director's Email	*

Champion's First Name	*
Champion's Last Name	*
Champion's Address 1	*
Champion's Address 2
Champion's City	*
Champion Country	*
Champion State	*
Champion's Postal Code	*
Champion's Phone	*
Champion's Fax
Champion's Email	*

Children Information

Number of Children in Orphanage
Number of Children who are Critically Ill
Number of Children who are Undernourished
Number of Caretakers
Is there sufficient staff to distribute products daily?	No Yes

Shipping Information

Date of Trip
Number of People Traveling
Luggage Space Available
Name
Address
City
Country
State	*
Postal Code
Phone
Email