WISH LIST
KITCHEN
BATH
SMALL APPLIANCES
Bath towels
Pots and pans
Toaster
Hand towels
Baking pan
Coffee maker
Wash cloths
Cookie sheet
Tea kettle
Shower curtain & rings
Measuring cups & spoons
Wall Clock
Bath mat
COOKING & BAKING
Vegetable peeler
Can opener
Paring knife
Cutting board
Colander
Waste basket
CLEANING UP
Dish rack
LAUNDRY
Dish cloths
Dish towels
Garbage can
Laundry basket
Broom
Iron
Dishes
Dust pan
Ironing board
Silverware
Mop
Hangers
Glasses
Bucket
SERVING
Cutlery tray
NOTES:
Pot holders
BEDROOM
Comforter
Linen Size
Sheets
Twin
Blanket
Full
Mattress Pad
Queen
Pillow
King
P.O. Box 25653
Rochester, NY 14625
Quantity
(585) 265-3383
HomeStartHope.org
APPLICATION
NAME
ADDRESS
PHONE NUMBER
INCLUDING YOURSELF, HOW MANY PEOPLE LIVE IN THE HOUSEHOLD?
CHILDREN’S NAMES
GENDER
AGES
To help us better understand who we serve please complete the following questions.
Answers are optional.
WHAT IS YOUR ETHNICITY?
WHAT IS YOUR AGE?
EMPLOYMENT STATUS
Under 18 years
African American
Employed for wages
18 to 24 years
Asian
Self-employed
25 to 34 years
Hispanic
Out of work and looking
for work
35 to 44 years
Pacific Islander
45 to 54 years
White
Out of work but not currently
looking for work
A homemaker
55 to 64 years
A student
WHAT IS YOUR
EDUCATION LEVEL?
Age 65 or older
WHAT IS YOUR MARITAL STATUS?
Retired
Completed some
high school
Unable to work
Single (never married)
High school graduate
Married
Completed some college
Separated
Associate degree
Widowed
Bachelor's degree
Divorced
Master/Doctorate degree
May HSH follow up with you for feedback, additional opportunities and future projects?
P.O. Box 25653
Rochester, NY 14625
HOW MANY HOURS PER WEEK
DO YOU USUALLY WORK
AT YOUR JOB??
35 hours a week or more
Yes
Less than 35 hours a week
No
(585) 265-3383
HomeStartHope.org