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 Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Preferred pronouns
*
She/her
He/him
They/them
Other
Race/ethnicity
*
Asian or Pacific Islander
Black or African American
Hispanic or Latino
Native American or Alaskan Native
White or Caucasian
Multiracial or Biracial
Other
Gender
*
Female
Male
Transgender Female
Transgender Male
Gender Fluid/Non-binary
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Number of children that will be living with you?
*
Birthdates of all children (if currently pregnant, please state so here)
*
Have you aged out of foster care?
*
Yes
No
Have you found your forever family?
*
Yes
No
Were you in the foster care system in your teenage years (12+)?
*
Yes
No
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
City
State / Province
Postal / Zip Code
Apartment?
*
Yes
No
Which floor?
*
Freight elevator?
*
Yes
No
Stairs in home?
*
Yes
No
Dog(s)?
*
Yes
No
Move in date
*
-
Month
-
Day
Year
Date
Furniture Requested
*
Couch/Sofa
Love Seat
Armchair
Coffee Table
TV Stand/Console
End Table
Dinette set (2 chair)
Desk with chair
Dinette set (4 chairs)
Dresser
Dinette set (6 chairs)
Night Stand
Table Lamp
Floor Lamp
Artwork
Bookshelf
Queen-sized bed
Pots/Pans
Full-sized Bed
Silverware
Twin-sized Bed
Plates/Bowls
Crib
Cups/Mugs
Other
I agree to let Chair-ity reach out to county workers to obtain information about my foster status on my behalf.
*
I agree
If you have your Ward Letter or Letter of Emancipation from foster care, please upload it here. This will speed up the process of verifying your foster status.
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How did you hear about us?
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Additional/Helpful Notes
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