Request form

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

Please note, complete one form for each family you are requesting for. For helpful hints on how to complete this form please click here.   

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

We look forward to receiving your request soon - thank you for your support of families in need.

Your Details

Your name *

Your organisation *

Email *

Your mobile number *

Family Information

Mother's initials or reference (to prevent duplication of orders)*

What Local Government Area does the family reside in? *

Does this family identify as Aboriginal or Torres Strait Islander? *

Does the family have a health care card? *

What are the causes of disadvantage for this family *

You may select multiple items by holding down your Ctrl or command key. If you chose 'other', please detail in the notes field at the end of the form.

Is this family connected with other support services? If so, who?

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

Baby's gender *

How many children are in the family in total? *

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

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

What is the age(s) and gender of the older siblings? (Please write G5, B6 etc.) *

Items Required

Does the family need a cot or bassinet? (choose one option please and note that cots are recommended from birth, and bassinets only last until the baby can roll, which can be as young as 10 weeks):

What type of pram would you like to request? (please choose one)

What car restraints do they need? (you may select multiple items by holding down your Ctrl or command key)

Note - If the family needs two car restraints of the same size please detail this in notes below.

What other items would you like to request? (you may select multiple items by holding down your Ctrl or command key):

Further details can be added in the comments area , Eg: Nappy size, Cot Mattress dimensions.

If they need clothes, enter the number of clothing bags they need. 

 Size   Boy  Girl
 UniPrem: 
Prem     
Birth-1    
1-2    
2-3
3-4
4-5
5-6
7-8
9-10
11-12

 

If they need shoes, enter the number of bags per size they need (C = child, Y = youth), there are approximately 4 pairs of shoes per bag

 Size   Boy  Girl
C5
C6
C7
C8
C9
C10
C11
C12
C13
Y1
Y2
Y3
Y4
Y5


If they need linen, enter the number of linen or bedding bags they need.  

 Cot Boy:   Single Bed Boy:   Bassinet Boy: 
 Cot Girl:   Single Bed Girl:   Bassinet Girl: 
 Cot Unisex:     Bassinet Unisex: 
Do you have any further notes or comments about this request?

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

 

Looking forward to receiving your request soon - thank you for your support of families in need.