DFB Beds4Kidz Referral Form

Beds4Kidz Referral Form

Approved referral partner use only.
This form is to be used and submitted by approved ISD partners only.

If you are an individual in need of furniture assistance, DO NOT complete this form. Please visit the Partner Agencies page at https://www.dallasfurniturebank.org/partner-agencies to contact a partner agency for assistance.

Non-referral submissions will be voided.
The information recorded in the form will be maintained with strict confidentiality and will only be used by DFB Staff for processing furniture requests, making contacts for outcome measures and for reporting demographic/statistical information.
Referring School Name*
School Name
ISD Name*
ex. Smalltown ISD
School Contact*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Request Information
Family Surname*
Last Name
Number of minor children in the household needing a bed?*
Child 1 Age*
Child 1*

MaleFemale
Child 2 Age
Child 2

MaleFemale
Child 3 Age
Child 3

MaleFemale
Child 4 Age
Child 4

MaleFemale
Child 5 Age
Child 5

MaleFemale
Child 6 Age
Child 6

MaleFemale
If a household has more than six (6) children in need of a bed, please provide the age and sex of additional children in the box below.
Additional children information:
Select what factor(s) caused the current need for program assistance.

No bed/sleeping on the floor or sofaSharing a bed with othersBed is unfit or poses a health riskStudent/family has requested a new bed
Client Demographic Information

The following information is used for reporting only.
Race & Ethnicity*

Black/African American/AfricanAsian American/Pacific Islanders/AsianHispanic/Latino/Latina/LatinxNative American/American Indian/IndigenousWhite/Caucasian/EuropeanMulti-Racial/Multi-Ethnic (2+ races/ethnicities)Decline to provideOther
Primary Language*
Please provide any additional information or needs.
Additional Notes
By submitting this form, I acknowledge that the child(ren) referred do not have a bed or their current bed/sleeping arrangement poses a potential health risk.
Should be Empty: