Luggage With Love Delivery Request

Luggage With Love Delivery Request
Eligibility: Children must have some connection to Cleveland County. The request must be made within one week of placement or by the case worker.

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 suitcase containing: 2 tops, 2 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 foster parent or kinship parent.
Placement Name*

First NameLast Name
Placement Email*
example@example.com
Placement Phone Number*
Please enter a valid phone number.
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.

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, bra's, ethnic hygiene items, 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, bra's, ethnic hygiene items, 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, bra's, ethnic hygiene items, 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, bra's, ethnic hygiene items, 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