Family Supply Request

Supplies Order Form
The Supply Order Form has been Updated. Please fill out the form below to let us know what supplies are needed. You will no longer automatically recieve certain items you will need to select them from the list. All items will be fulfilled on your enrollment date. All orders must be picked up within the week of being notified. If not picked up ypur order will be moved to the next month.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number
Email*
Preferred Spoken Language / Idioma hablado preferido*

EnglishSpanishOther/Otro
What is your current living situation? / ¿Cuál es su situación de vida actual?**

Castaic Interim HouseNewhall Interim HouseHotelMy own home (own/rent)HomelessLiving with Family/FriendsOther /Otro
How many adults are in your family?*
How many children are in your family?*
Have you met with your Case Manager this month? A 45 minute update meeting with your case manager is required prior to picking up supplies.*

YesNo
Have you provided your Case Manager with a 2026 budget?*

yesno
Please select items from the list below, based on your needs.

Paper Towels/toalla de papelShampoo/champúConditioner/acondicionadorToilet Paper/papel higiénicoBaby Shampoo / Champú para bebésBleach / LejíaBody Wash / Gel de bañoMultipurpose Cleaning Spray / Spray de limpieza multiusosDeodorant (Women) / Desodorante (mujeres)Deodorant (Men) / Desodorante (hombres)Detergent (Regular) / Detergente (reg)Dish Washing Soap / Jabón para lavar platosClorox Wipes / Toallitas CloroxDryer Sheets / Hojas Para SecadoraGlass Cleaner / Limpiadora de videoHand Sanitizer / Alcohol en gelHand Soap / Jabón de manosKlennex / PañuelosRazors / Maquinillas de afeitarSanitary Pads (with wings) / Toallas sanitarium con alasSanitary Pads (without wings) / Toallas sanitarium sin alasShaving Gel / Crema de afeitarDish Sponges / EsponjasToothbrush (adult) / Cepillo de dientes (adulto)Toothbrush (child) / Cepillo de dientes (niño)Toothpaste / Pasta de dientes (niño)Toothpaste / Pasta de dientes (adulto)Tooth Floss / Hilo dental
Diapers/Wipes
If you need additional items other than what is listed above, please let your Case Manager know.
Do you have any updates you'd like to share with your Case Manager?*
Example: New Employment, Change of Address, etc. / Ejemplo: Nuevo Empleo, Cambio de Dirección, etc.
We will contact you to set up a time for you to come in for supplies and/or a case management meeting.*

I understand
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Supplies Order Form