M-Power Tangible Item Delivery Form
Name
*
First Name
Last Name
Race
*
Black or African American
White or Caucasian
Asian
Native Hawaiian or Pacific Islander
American Indian or Alaskan Native
Unknown
Ethnicity
*
Hispanic
Non-Hispanic
Haitian
HMHB Program
*
Please Select
MOMS
City
*
Client Zip Code
*
Client Bus Pass #
Bus Pass Type
3 Day
7 Day
10 Day
31 Day
Gas Card #
Gift/Food Card #
Welcome to World Package: Child's DOB-
-
Month
-
Day
Year
Date
Costco or Item(s) Requested and/or Delivered:
Items Given
Rows
Child Name
Child Date of Birth
Diaper Size
Quantity
Other
A
B
C
D
Gender
Male
Female
Item Value (If not previously listed above)
Total value (If more than one item delivered)
Manager
Manager Approval:
Date
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Staff
Staff Name
Please Select
Ieshia Scott
Vanessa Charles
Cheryl Rivera
Kayla Castillo
Linda Levasseur
Mica Becker
Yanique Taylor
Kay-Ann Marshall
Kira Swihart
Kari Keagle
Staff Signature:
Date
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Client
Participant's Signature:
Date
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Save
Submit
Should be Empty: