Referral Form for Gift Cards

The purpose of this form is to request grocery gift cards for resettled families. We are providing $100-$300 per household, depending on the number of people. The grocery gift cards will be for Fred Meyer, Target, or Winco.

Requests for gift cards are for families who have been resettled in the last five years and are experiencing food insecurity, job loss, or other significant hardship.

Gift cards must be given to the client, and not used to purchase items on their behalf. Upon filling out this request form, you agree to give the gift cards directly to the client.

Thank you for your work!

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Date Submitted

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Client's Full Name:*

If this request is for the whole family, please include the full name of the head of the family here + "Family." (Ex. Hussain Muhammad and Family.) If this is for an individual client, please only include the client's name.

Client's Full Name:*

Client's Country of Origin:*

Date of Arrival:*

If you're unsure, the month and year, or only the year is appropriate.

Client's Address:*

We will not contact the client but do need this information for our records.

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Client's Phone-Number:*

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Resettlement Agency that Resettled Client in Oregon:*

(Catholic Charities of Oregon, Ecumenical Ministries of Oregon, IRCO, Lutheran Communities Services Northwest)

Number of People in Family:*

Genders and Ages in Family:*

(Ex: 37 year old mom, 9 year old girl, 7 year old boy)

Name of Person Referring:*

Email Address of Person Referring:*

Referring Organization:

Please state the organization you represent.

Title/Role:*

Additional Comments:

Feel free to include anything else you would like us to know.

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Referral Form for Gift Cards

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