Keeping Families Covered
* Required
Email address
*
Your email
DIRECT-TO-CLIENT INTAKE FORM
Contact Information
Referred by:
*
Your answer
Full Name:
*
Your answer
Address:
*
Your answer
City:
*
Your answer
State:
*
Your answer
ZIP Code:
*
Your answer
Email:
*
Your answer
Cell Phone:
*
Your answer
Required Information
Please note that your request will be denied if you fail to provide the required information.
Date of birth:
*
MM
/
DD
/
YYYY
Are you receiving help from other agencies?
*
Yes
No
If yes, which agencies?
*
Your answer
Driver's license number:
*
Your answer
State:
*
Your answer
Marital status:
*
Single
Married
Separated
Divorced
Widow
Race:
*
Hispanic
African American
Caucasian
Native American
Asian
Other:
Required
The following forms of identification are required to receive assistance:
Government Issued Photo ID (Driver’s License, State ID, Military ID, VISA, passport) for parent
Birth Certificate (for every child in need of assistance)
Family Information & Items Needed
Per our policy, we do not provide any items for unborn children. If you are currently pregnant, we can help you with maternity wear until your delivery. Once your child is born and you have their birth certificate, you are welcome to apply for assistance for them.
If you are pregnant and need maternity wear, please select your size:
S
M
L
XL
Clear selection
Please list the first names of the children and what each needs. Sizes must be provided for clothing and shoe requests.
Child 1 Name:
*
Your answer
Child 1 Age:
*
Your answer
Child 1 Gender
*
Female
Male
Other:
Child 1 Clothing Size
*
Choose
Newborn
3M
6M
9M
12M
18M
24M
2T
3T
4T
5T
6
7
8
10
12
Please list desired items for Child 1 :
*
Your answer
Child 2 Name:
Your answer
Child 2 Age:
Your answer
Child 2 Gender
Female
Male
Other:
Clear selection
Child 2 Clothing Size
Choose
Newborn
3M
6M
9M
12M
18M
24M
2T
3T
4T
5T
6
7
8
10
12
Please list desired items for Child 2 :
Your answer
Child 3 Name:
Your answer
Child 3 Age:
Your answer
Child 3 Gender
Female
Male
Other:
Clear selection
Child 3 Clothing Size
Choose
Newborn
3M
6M
9M
12M
18M
24M
2T
3T
4T
5T
6
7
8
10
12
Please list desired items for Child 3 :
Your answer
Child 4 Name:
Your answer
Child 4 Age:
Your answer
Child 4 Gender
Female
Male
Other:
Clear selection
Child 4 Clothing Size
Choose
Newborn
3M
6M
9M
12M
18M
24M
2T
3T
4T
5T
6
7
8
10
12
Please list desired items for Child 4 :
Your answer
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