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.Format: (000) 000-0000.
Case ManagerSocial WorkerSchool CounselorHousing Program StaffHospital/Clinic StaffFaith-Based StaffCommunity OrganizationOther (specify)
YesNo
Explain previous referrals/support
Parent/Guardian Full Name*
Client Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
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

CoatsWinter Boots/ShoesGloves/MittensScarvesHats/BeaniesThermal WearBlanketsWinter Socks
YesNo
If YES, describe the urgent need*
Allergies / Sensitivities / Special Needs*
YesNo
Delivery Notes / Instructions*
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*
Date Submitted*

MonthDayYear
Date
YesNo
Explain previous referrals/support
Should be Empty: