This guide is to support you to get the most from each request you make from Eureka Mums. 

Please note to access our services all social workers and maternal and child health nurses must be registered with Eureka Mums.

If you are not yet registered, please register here prior to completing this form.

Please ensure that you complete one request form for each family.

For further assistance or for emergency requests, please contact the Social Services Coordinator via email. 

Your Details

Q: Your name?

Please enter your full name including first name and surname. If your organisation does not allow you to disclose your surname, please include your first name only.

Q: Your organisation?

Please enter your organisation’s full name, do not put acronyms. If your organisation is Victoria wide, please include your organisation and the suburb it’s located, e.g. SalvoConnect – Ballarat

Q: Email?

Please enter the work email you used at registration - if you do not use your registered email address the form will not submit properly. 

Q: Your mobile number?

Please enter your work mobile number in full. If you do not have a mobile number please enter your work’s main office number.

Family Information

Q: Mother’s initials or reference (to prevent duplication of orders)

Please enter the initials for the mother of the child and/or children. In the absence of a mother, please enter the details of the guardian, carer or father. This collection of personal information will be stored securely as required under the Australian Privacy Act. This is important for us to detect and prevent duplication of orders. 

Q: What Local Government Area (LGA) does the family reside in?

Please click on the text box and choose LGA.

Q: Does this family identify as Aboriginal or Torres Strait Islander?

Click on the text box and select the correct option.

Q: Does the family have a Health Care Card?

Please select Yes or No. This does not effect eligibility for our service.

Q: What are the causes of disadvantage for this family? You may select multiple items by holding down your Ctrl or command key on your keyboard.

Please click on the text box, select the cause from the list available. You may select more than one by holding down your Ctrl or command key on your keyboard. If you have selected ‘other’ can you please use the further notes or comments box at the end of this form just before you submit. In this box you can provide another cause for disadvantage.

Q: Is DHHS involved with this family/child?

Please select Yes or No. This does not effect eligibility for our service.

Q: Is this family connected with other support services, if so who?

Please enter the other service(s) that this family is supported by. For example, Child Protection might also be supporting this family.

Q: What is the due date of baby or birth date of the of the youngest child? (Please write dd/mm/yyyy)

Please enter the day, month and year of the due date or the birth date of the youngest child in the family. Please ensure that it is entered in the format as requested above.

Q: Baby or youngest child's gender?

Please select the option that applies to the youngest child. If there are twins, please select twins and let us know the gender of them in the further notes or comments box located at the end of this form.

Q: How many children are there in this family in total?

Please enter the total number of babies (under 12 months of age) and children in this family, including baby or babies due to be born. For example, mum is 11 weeks pregnant, there is a two-year-old boy, seven year old girl and 12 year old girl. Please enter four children.

Q: How many are we directly supporting with this request (including babies due to be born)? 

Please enter the number of children in the family who will be receiving items from this request. 

Q: How many are younger than 12 months (including the one(s) due)?

Please enter the number of babies, under 12 months of age in this family. This is to also include any babies yet to be born. For example there are two babies (twins) 11 months old, mum is eight weeks pregnant. So please enter three babies.

Q: What are the age(s) and gender of the older siblings? (Please write G5, B6, etc.)

Please enter the age and gender of children (older than 12 months) for the family you are requesting for. For example if there is a 1 year-old boy and three year-old girl please enter – B1 and G3.  

Items Required

Q: Cot or bassinet

Please note that cots are recommended from birth, and bassinets only last until the baby can roll, which can be as young as 10 weeks. Please select either cot or bassinet and enter the number that this family needs (cot is preferred).

Q: Pram

Please enter 1 in the type of pram this family would prefer. 

Q: Car restraint

Please enter 1 next to the type of car restraint this family needs. If you need more than one car restraint (for siblings or multiples) please enter the relevant number next to each type.

It is the law for all children up to the age of 7 to be in a child restraint or booster seat when travelling in a vehicle. Choosing the right child restraint for a child will depend on their age and size. 

To keep a child safe, the restraint must also be properly adjusted, fastened, and fitted to the vehicle. More information is available from the Vic Roads website. All Eureka Mums car restraints have tether straps. 

Q: Nappies

If you select nappies please tell us which size(s) you require. If not required, just leave blank.

Please note that the nappy sizes listed below are a guide only, so to ensure the correct size(s) is provided please obtain accurate sizing from your families.

• Newborn (up to 4kg)
• Infant (4 to 8kg)
• Crawler (6 to 11kg)
• Toddler (10 to 15kg)
• Walker (14 to 18kg)
• Junior (16kg+)

We also have Night Pants available for older children:

• 4 - 7 years old
• 8 - 15 years old

Q: Other items

Please enter 1 next to any required items. Please note we rely on donations, so we cannot guarantee supply but we'll do our best.

Q: Clothing bags 

Please enter the number of bags required per size and gender. Please note the clothing bags contain 80-100 items.

Q: Shoes

Please enter "1" on the relevant box for size and gender. If not required just leave blank. Note that there are approximately 5 pairs of shoes per pack. 

Please obtain accurate sizing from your families to ensure the correct sizes are provided.

Q: Linen bags

Please enter the number of bags required. These include wraps and sleeping bags. Please note that cot as well as single bed linen can be requested here. Eureka Mums also provides unisex cot linen if the gender of the baby is unknown.

Q: Do you have any special requests, further notes or comments about this request?

Please click on this text box to enter any further information you can provide about your request or for any additional needs.

Q: Please confirm that you agree with the terms of our Service Policy?

Please read our Service Policy if you haven’t already, and click on the text box to select Yes. 

Q. Opening times

Please read the opening times information and enter your preferred collection date. 

Don't forget to click the Submit button at the end of the form!