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Southeast Family Center Armed Services YMCA

2190 Jet Wing Drive
Colorado Springs, CO 80916

P 719 622 9622
F 719 622 3555

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Operation Comfort Quilt Request Form

* Required

Title Captain Chief Warrant Ofc. 2 Chief Warrant Ofc. 3 Chief Warrant Ofc. 4 Chief Warrant Ofc. 5 Chief Warrant Officer 2 Chief Warrant Officer 3 Chief Warrant Officer 4 Chief Warrant Officer 5 Colonel Corporal DR First Lieutenant JR Lieutenant Colonel Lt. Major MISS MR MRS Mrs. MS Ms. Private 1 Private 1st Class Private 2 Second Lieutenant Sergeant Sergeant First Class Specialist Staff Sergeant TSgt Warrant Officer

Parent/Guardian First Name *

Parent/Guardian Last Name *

Email Address *

Home Address *

City *

State *

Zipcode/Postcode *

Country * -- Select Country -- AFGHANISTAN ALAND ISLANDS ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CâTE D'IVOIRE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUINEA GUINEA-BISSAU GUYANA HAITI HEARD ISLAND AND MCDONALD ISLANDS HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA, REPUBLIC OF KUWAIT KYRGYZSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, OCCUPIED PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT HELENA SAINT KITTS AND NEVIS SAINT LUCIA SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA AND MONTENEGRO SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN, PROVINCE OF CHINA TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES UNITED STATES MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VENEZUELA VIETNAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA YEMEN ZAMBIA ZIMBABWE

Service Member First Name *

Service Member Last Name *

Branch of Service * Colorado Springs Area Military Installations only*

Children's Names, Ages, and Genders * Please list all children for which you are requesting a quilt (Example: Child1 age male, Child2 age female, and so on)

Home Phone Number *

Work Phone Number

Cell Phone Number

Attach File (100Mb Limit *) • Photos should be between 250 KB and 2000 KB (2MB) for optimum print qualitity. • Submit 4 photos for a quilt and 6 photos for a pillow. • Be sure to include the child’s name in the photo file. • Please review and select photos you wish to submit prior to completing this form. • Quilt and pillow requests without submission of photos will be considered incomplete. • To attach photos, save as jpeg files in a compressed (zipped) folder and upload below. *4 photos for a quilt and 6 photos for a pillow.

Enter Word Verification in box below *

Friend Email Address

Friend Email Address

Friend Email Address

Friend Email Address

Friend Email Address

Friend Message Hi, I think you should check out this site. http://southeast.ppymca.org.

ASYMCA/Operation Kid Comfort Release: The Armed Services YMCA is actively pursuing corporate, business and individual support for Operation Kid Comfort and the many other programs we offer. We would appreciate your permission to use photographic images provided for these projects, as well as photographs of the finished quilts and photographs taken at Operation Kid Comfort workshops and events for these purposes. Please read our privacy statement and approve or disapprove the use of your image, the image of your child(ren) and/or your spouse below. Armed Services YMCA Privacy Policy: We do not disclose any nonpublic personal information about you to anyone, except as permitted by law. We restrict access to your personal information to those employees and volunteers who need to know that information to provide products and/or services to you. We maintain physical, electronic and procedural safeguards that comply with federal standards to guard your nonpublic personal information. ASYMCA/Operation Kid Comfort Photo Release* I give permission to use photographic images I do not give permission to use photographic images