FTFDC REQUEST FOR SUPPLIES AND SUPPORT

REQUEST FOR SUPPLIES AND SUPPORT

Please fill out this form with your family's information and the specific needs of the child(ren) *AFTER* they have arrived in your home within the first 48 hours. We hope to make this transition just a little bit easier for you and a little bit happier for your child!
We deliver FosterCare Packages to the following cities and counties:

DC, MONTGOMERY, ARLINGTON, ALEXANDRIA, FAIRFAX, LOUDOUN, PRINCE WILLIAM, MANASSAS, & FAUQUIER.

If you live in PRINCE GEORGE or STAFFORD, please fill out the request, but note that deliveries may take longer than the 24-48 hour window as we continue to build partners and volunteers in those regions.

Also, please provide 48 hours of grace during the holiday season as deliveries may be delayed due to team's availability.
Is the child currently in the home? We only deliver care packages after placement.*
Due to the quick changing nature of foster care, we only make deliveries after the child has been placed in your home, within the first 48 hours of their arrival. If you are expecting the child soon, please explain more below and request a care package after you've welcomed the child(ren) into your home.
Please explain when you are expecting the child to arrive, what age and gender the child is, and any other important information we should know.
We will use this information to begin coordinating a delivery to you. But it is important that you fill this form out (with more details) AFTER the child enters your home.
Parent / Caregiver Information
Parent / Caregiver Name*

First NameLast Name
Parent / Caregiver Email*
example@example.com
Parent / Caregiver Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who is filling out this form?
Case Worker Name:

First NameLast Name
Case Worker Phone Number

Area CodePhone Number
Case Worker Email*
example@example.com
If not the parent / caregiver or caseworker, please type your name and contact information below:

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Which County DSS Office / Licensing Agency are you working with?*
Family Information
How many people are in your household?*
Does anyone in the family have a food allergy?*

YesNo
Please explain.
Number of Children Being Placed
Child's Information (add an additional row for each child placed today). Race information helps us provide appropriate skin and hair care product.*
Please list any OTHER children already in your home, not the new child(ren). We would love to provide something for each additional child in the home, if we have items available. Please list the gender and ages of any other children currently in the household (NOT including the child newly arriving). If no other children are in your home, just put NA.*
Child's Information
Clothing Size
If size is not listed, please add to the notes section at the bottom.
Does the child wear underwear or diapers or pull ups
Underwear/Diaper size
Does the child need a bottle, sippy cup, or water bottle?

BottleSippy cupWater bottle
Formula Type (if applicable)
Child 2 Information
Child 2: Clothing Size
If size is not listed, please add to the notes section at the bottom.
Child 2: Does the child wear underwear or diapers or pull ups
Child 2: Underwear/Diaper size
Child 2: Does the child need a bottle, sippy cup, or water bottle?

BottleSippy cupWater bottle
Child 2: Formula Type (if applicable)
Child 3 Information
Child 3: Clothing Size
If size is not listed, please add to the notes section at the bottom.
Child 3: Does the child wear underwear or diapers or pull ups
Child 3: Underwear/Diaper size
Child 3: Does the child need a bottle, sippy cup, or water bottle?

BottleSippy cupWater bottle
Child 3: Formula Type (if applicable)
Child 4 Information
Child 4: Clothing Size
If size is not listed, please add to the notes section at the bottom.
Child 4: Does the child wear underwear or diapers or pull ups
Child 4: Underwear/Diaper size
Child 4: Does the child need a bottle, sippy cup, or water bottle?

BottleSippy cupWater bottle
Child 4: Formula Type (if applicable)
Child 5 Information
Child 5: Clothing Size
If size is not listed, please add to the notes section at the bottom.
Child 5: Does the child wear underwear or diapers or pull ups
Child 5: Underwear/Diaper size
Child 5: Does the child need a bottle, sippy cup, or water bottle?

BottleSippy cupWater bottle
Child 5: Formula Type (if applicable)

REQUEST FOR SUPPLIES AND SUPPORT

Parent / Caregiver Information

Family Information

Child's Information

Child 2 Information

Child 3 Information

Child 4 Information

Child 5 Information

Delivery Information