Sensory Bag Request

Need assistance with this form, email cin@boostkc.org.

Requester

Requesting School District

School Name

Select a Grade Level

Requester email address

Requester phone number

Format: (000) 000-0000.

Grade Level

School/Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is the delivery address the same as above?

Preferred Delivery Location and Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

The following items will be in each bag.

Request Options:

Replenishment Sensory Bag Items

Schools may request replace items that are lost, broken or worn-out at the end of the school year.

Requests for replace items must be made through the Sensory Bag Request form.

End-of-Year Replacement Needs

Activity Board - Indicate the quantity up to 1 (Broken item must be returned to CIN)

Sticker Strips - Indicate the quantity up to 5

Worry Stones - Indicate the quantity up to 5

Stress Balls - Indicate the quantity up to 5

Head Phones - Indicate the quantity up to 2 (Broken item must be returned to CIN)

Fidget Spinners - Indicate the quantity up to 5

Puzzle Cube - Indicate the quantity up to 5

End-of-Year Replacement Needs Comments (optional)

Sensory Bag Request Form