Quilt Request Form

Operation Kid Comfort Quilt Request Operation Kid Comfort Quilts are for children of deployed service men and women. To receive a quilt, please submit this completed form along with nine photographs of the deployed service member [CD or regular pictures]. Submit completed request form and required photos to: Operation Kid Comfort Armed Services YMCA San Diego 3293 Santo Road San Diego, CA 92124 Parent/Guardian Last Name: Service Member Last Name:

______First Name:

_____

First Name:

Duty Station (Please Circle): Naval Base San Diego - Naval Base Pt. Loma – Naval Base Coronado – MCRD – Miramar - Harbor Drive San Diego – Camp Pendleton 29 Palms Command: ______________________________________________________________ Child(ren)Name/Gender/Age: Email: Mobile Phone:

______ Other Phone:

______

Address: City:________________________________ State______ Zip Code:_________________ ASYMCA/Operation Kid Comfort Release:

In order to cultivate potential donors in support of the Operation Kid Comfort program we would appreciate your permission to use photographic images provided in your quilt request as well as photographs of the finished quilts. The ASYMCA will only use your images, the images of your child(ren) and/or your spouse for legitimate purposes. □ I give permission for photographic images of my spouse, my child(ren), my family and myself to be used for ASYMCA/Operation Kid Comfort media, promotional and fundraising purposes. □ I DO NOT give permission photographic images of my spouse, my child(ren), my family and myself to be used for ASYMCA/Operation Kid Comfort media, promotional and fundraising purposes.

Signature:

Date: