xHope Caring for Kids Kit / Items Request Form
A Separate Request MUST be filled out for each child
COUNTY
*
Sacramento
Amador/Calaveras
Other
Please check all that apply:
*
Foster
Adopt
Kinship/Guardianship
Single Parent
Unhoused
Newcomer/Refugee
Transportation Limitations
Unaccompanied Minor
Other
Request Date
-
Month
-
Day
Year
Date
Who is filling out this form?
*
Caregiver
Case Manager/Social Worker
Other
Please explain why you are submitting a request on behalf of this child:
*
Child's Name
*
Gender
*
Boy
Girl
Other
Age
*
School ID#
*
Grade
*
School Attending
*
School District
*
City of Residence
*
Items distributed will be based on availability and at the discretion of xHope, Inc.
We are typically unable to accommodate requests for specific styles and colors of clothing.
Please select all resources needed:
*
Community Closet/Co-op Closet
Backpack w/school supples
Hygiene Kit (filled with age-appropriate personal care items)
Comfort Kit (Pajamas, socks, blanket or stuffed animal)
Diaper Bag Kit
Other
Diaper Size
Newborn
Size 1
Size 2
Size 3
Size 4
size 5
Sleeper Size
Newborn
0-3 M
3-6 M
6-9 M
12 M
18 M
Pajama Size
2T
3T
4/5
6/7
8
10/12
14/16
Adult Small
Adult Medium
Adult Large
Adult XL
Other
Size
*
Please Select
Girls
Boys
Women's
Men's
Girls Tops
Please Select
2T
3T
4-5
6
7-8
10-12
14-16
other
Girls Bottoms
Please Select
2T
3T
4-5
6
7-8
10-12
14-16
other
Boys Tops
Please Select
2T
3T
4
5-6
7-8
8-10
12-14
16-18
0ther
Boys Bottoms
Please Select
2T
3T
4
5-6
7-8
8-10
12-14
16-18
other
Women's Tops
Please Select
XS
S
Med
Large
XL
Other
Other
Mens Tops
Please Select
XS
S
Med
Large
XL
Other
Other
Women's Bottoms
Please Select
XS
Sm
Med
Large
XL
0
2
4
6
8
10
12
14
16
18
20
Other
Other
Men's Bottoms
Please Select
XS
Sm
Med
Large
XL
XXL
Other (waist size)
Other
Shoe Size (no half sizes)
Other
Additional Notes or Information:
Referred By INFORMATION
Referred by:
*
Social Worker
Case Manager
Family Liason
Counselor
Administrator
Teacher
Other
Name of Referring PERSON
*
First Name
Last Name
Name Referring AGENCY or ORGANIZATION
*
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Parent/Guardian/Caregiver INFORMATION
Parent/Guardian/ Caregiver NAME
*
First Name
Last Name
Parent/Guardian/ Caregiver PHONE
*
-
Area Code
Phone Number
Parent/Guardian/ Caregiver EMAIL
*
example@example.com
Who should we contact for pickup?
*
Caregiver
Referring Person
THANK YOU!
ONCE READY, YOU WILL RECEIVE A TEXT/PHONE CALL/EMAIL TO SCHEDULE A DATE/TIME TO PICK UP ITEMS FROM OUR OFFICE. PLEASE CONTACT US AT 916-937-6477 OR EMAIL admin@xhopemissions.org WITH ANY QUESTIONS.
Pick-Up Date
-
Month
-
Day
Year
Date
ITEMS RECEIVED
OUTFIT
SHOES
SOCKS
UNDERWEAR
JACKET/COAT
HOODIE
SHIRT
PANTS
PAJAMAS
BLANKET
STUFFED ANIMAL
HYGIENE KIT
BACKPACK
DIAPER BAG KIT
DIAPERS
GENTLY USED CLOTHING
GIFTCARD
Other
VALUE $
STAFF NOTES
Submit
Should be Empty: