Luggage With Love Delivery Request

Luggage With Love Delivery Request
Eligibility: Children must have some connection to Cleveland, McClain or Garvin Counties. This is a one time emergency clothing resource for new placements.

Deadlines: Forms submitted by 4 pm will be delivered the same day. Requests received after 4 pm or on weekends will be delivered by the next business day.

Items Included: a duffle bag containing: 3 tops, 3 bottoms, 3 pairs of socks, 3 pairs of underwear, 1 pair of pajamas, 1 pair of shoes, 1 coat/jacket/swimsuit (depending on the season), 1 blanket, 1 age-appropriate book or toy, & 1 small personal hygiene kit.

All clothing is new, no used clothing is included.
Date of Submission

MonthDayYear
Placement Contact Info

Please provide the information for the placement provider (i.e. foster/kinship parent, etc.).
Placement Name*

First NameLast Name
Placement Email*
example@example.com
Placement Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Placement Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Court Case and Worker Information

Please provide the information for the court case and the worker.
KK or Court Case Number*
Date of Placement*

MonthDayYear
Date
Workers Name*

First NameLast Name
Workers Email*
example@example.com
Workers Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
County of Jurisdiction
County in which the child's case worker or court case is located.

Child Information

Please provide the information for the child/children you would like to support.
Child Name*

First NameLast Name
Child Date of Birth*

MonthDayYear
Date
Child Age
Gender of Child (identifies)*

MaleFemale
Ethnicity of Child*
Pant Size*
Shirt Size*
Shoe Size*
Child Underwear Size*
Diaper Size*
Special Needs or Comments
(i.e. Pull-ups, night diapers, specific hygiene items, specific sizing, etc.)
Would you like to submit another request with the same placement and worker information?*

YesNo
Child #2 Information

Please provide the information for the child/children you would like to support.
Child #2 Name*

First NameLast Name
Child #2 Date of Birth*

MonthDayYear
Date
Child #2 Age
Gender of Child #2 (identifies)*

MaleFemale
Ethnicity of Child #2*
Child #2 Pant Size*
Child #2 Shirt Size*
Child #2 Shoe Size*
Child #2 Underwear Size*
Child #2 Diaper Size*
Special Needs or Comments
(i.e. Pull-ups, night diapers, specific hygiene items, specific sizing etc.)
Would you like to submit another request with the same placement and worker information?*

YesNo
Child #3 Information

Please provide the information for the child/children you would like to support.
Child #3 Name*

First NameLast Name
Child #3 Date of Birth*

MonthDayYear
Date
Child #3 Age
Gender of Child #3 (identifies)*

MaleFemale
Ethnicity of Child #3*
Child #3 Pant Size*
Child #3 Shirt Size*
Child #3 Shoe Size*
Child #3 Underwear Size*
Child #3 Diaper Size*
Child #3 Special Needs or Comments
(i.e. Pull-ups, night diapers, specific hygiene items, specific sizing etc.)
Would you like to submit another request with the same placement and worker information?*

YesNo
Child #4 Information

Please provide the information for the child/children you would like to support.
Child #4 Name*

First NameLast Name
Child #4 Date of Birth*

MonthDayYear
Date
Child #4 Age
Gender of Child #4 (identifies)*

MaleFemale
Ethnicity of Child #4*
Child #4 Pant Size*
Child #4 Shirt Size*
Child #4 Shoe Size*
Child #4 Underwear Size*
Child #4 Diaper Size*
Child #4 Special Needs or Comments
(i.e. Pull-ups, night diapers, specific hygiene items, specific sizing etc.)
Should be Empty:

Luggage With Love Delivery Request

Placement Contact Info

Court Case and Worker Information

Child Information

Child #2 Information

Child #3 Information

Child #4 Information