BED REQUEST FORM

BED REQUEST FORM

SERVING ALL OF LAKELAND FLORIDA AND SURROUNDING TOWNS WITHIN 10 MILES

Every child deserves a safe and comfortable place to sleep. If you are seeking a bed for a child in your household, please complete the form below. The information you provide will help us verify eligibility and coordinate assistance.

Who may complete this form?

This form may be completed by a church, agency, or nonprofit that is advocating for a family seeking a bed for a child.

Who is eligible?

*The child must not have a safe, appropriate bed of their own. (Up to age 21)

*Additional eligibility requirements may apply based on program availability and service area.

*********ALL BEDS ARE TWIN BEDS***********

*************AT THIS TIME WE DO NOT PROVIDE BUNKBEDS***********

WE DELIVER TO ALL OF LAKELAND AND THE SURROUNDING TOWNS WITHIN 10 MILES.

**************ALLOW 2 WEEKS FOR DELIVERY*****************

Name of Organization requesting the beds on behalf of children. (Church, agency, nonprofit etc)

Organization Name

Name of person advocating for the family

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

E-mail

example@example.com

Children's Information *please add a row for each child you are registering.

NAME

First NameLast Name

Street

City

Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Preferred method of contact

Please briefly describe the hardship and why this bed is needed for the child.

Family Delivery Info