SANTA'S CASTLE COAST GUARD REFERRAL FORM

Coast Guard Referral

Section 1: Service Member Being Referred

Fields with an * must be completed in order for the Santa's Castle team to process the referral.

Date

Service Member Rank

Service Member First Name

Service Member Last Name

Service Member's Personal Email (DO NOT provide a .mil address.)

Service Member's Personal Phone Number (This should be a cell phone number. We will use this number to contact the SM if we have any questions prior to his/her appointment.)

Service Member's Alternate Phone Number (If you know an alternate number for the SM, either a landline or a spouse's number, provide it here.)

List Unit

Location

Status

Married

Single

Is the spouse Military or Non-Military?

Military

Non-Military

Spouse Rank

Spouse First Name

Spouse Last Name

List Spouses' Unit

Section 2: Dependent Children

Accurate information on the SM's child(ren) helps us ensure we have appropriate inventory.

Infants (0 - 12 months) - Please put the number of infants.

Boys - Please put the number of children in the age group.

Boys (1yr- 2yr)

Boys (2yr - 3yr)

Boys (3yr - 5yr)

Boys (6yr - 9yr)

Boys (10yr - 13yr)

Boys (14yr - 17yr)

Girls (1yr - 2yr)

Girls (2yr - 3yr)

Girls (3yrs - 5yrs)

Girls (6yr - 9yr)

Girls (10yr - 13yr)

Girls (14yr - 17yr)

Special Needs Children (If you know that the SM has a special needs child or children, help us be prepared.)

Section 3: Referring Individual

Complete all information in this section for the Point of Contact for this referral.

Referrer Rank

Referring Individual First Name

Referring Individual Last Name

Referring Individual Email Address- MUST be an official military/.mil email.

Referring Individual Unit

Referring Individual Duty Phone Number

Referring Individual Cell Phone Number

Referrer Remarks

Electronic Signature of Referring Individual (Type in your legal name with military title. This is your electronic signature)

I affirm that all information submitted is accurate to the best of my ability.