Self Referral Form

Self Referral Form

Please fill out the information below to be referred to Chair-ity, Inc., and we will contact you to coordinate a furniture delivery once your information has been verified!
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Preferred pronouns*

She/herHe/himThey/themOther
Race/ethnicity*

Asian or Pacific IslanderBlack or African AmericanHispanic or LatinoNative American or Alaskan NativeWhite or CaucasianMultiracial or BiracialOther
Gender*

FemaleMaleTransgender FemaleTransgender MaleGender Fluid/Non-binaryOther
Phone Number*
Please enter a valid phone number.
Email (if applicable)
example@example.com
Number of children that will be living with you?*
Birthdates of all children*
Have you aged out of foster care?*

YesNo
Have you found your forever family?*

YesNo
Were you in the foster care system in your teenage years (12+)?*

YesNo
Please explain your situation further:*
County you aged out of*
Program you are in, if applicable
Name of social worker you are/have been working with*
Contact info for social worker (email or phone number)*
Address where furniture is needed*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Apartment?*

YesNo
Which floor?*
Freight elevator?*

YesNo
Stairs in home?*

YesNo
Dog(s)?*

YesNo
Furniture Requested*

Couch/SofaLove SeatArmchairCoffee TableTV Stand/ConsoleEnd TableDinette set (2 chair)Desk with chairDinette set (4 chairs)DresserDinette set (6 chairs)Night StandTable LampFloor LampArtworkBookshelfQueen-sized bedPots/PansFull-sized BedSilverwareTwin-sized BedPlates/BowlsCribCups/MugsOther
Additional/Helpful Notes
Should be Empty: