Referral-Only Request Form (Agency Submits for Client)

Referral-Only Request Form (Agency Submits for Client)

Use this form to submit a clothing support request for a client through your agency. Please complete all required sections accurately.
Agency/Organization Name*
Representative Full Name*
Representative Job Title*
Representative Email*
example@example.com
Representative Phone Number*
Please enter a valid phone number.
Your role with the client*

Case ManagerSocial WorkerSchool CounselorHousing Program StaffHospital/Clinic StaffFaith-Based StaffCommunity OrganizationOther (specify)
Has your agency referred this family before?*

YesNo
Explain previous referrals/support
Parent/Guardian Full Name*
Client Phone Number*
Please enter a valid phone number.
Client Email (optional)
example@example.com
Client Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Number of Adults in Household*
Number of Children in Household*

Household Members & Clothing Sizes

Winter Clothing Needed*

CoatsWinter Boots/ShoesGloves/MittensScarvesHats/BeaniesThermal WearBlanketsWinter Socks
Does this family need items urgently due to cold weather?*

YesNo
If YES, describe the urgent need*
Allergies / Sensitivities / Special Needs*
Do they have a safe and secure place for Amazon delivery?*

YesNo
Delivery Notes / Instructions*
Verification Statements (ALL MUST BE CHECKED)*

I verify that this family is experiencing financial hardship.I confirm that the information provided is accurate and truthful.I confirm that my agency provides case management or support to this family.I confirm this request is not duplicated by another agency.I confirm the family consents to receiving items via Amazon delivery.I understand that assistance is based on funding, inventory, and availability.
Representative Signature*

Clear
Date Submitted*

MonthDayYear
Date
Has your agency referred this family before?

YesNo
Explain previous referrals/support
Should be Empty: