Contact information

Attendees

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First name

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Last name

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Phone

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Phone type
Email address

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Email type

Address

Address

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Apartment, suite, etc. (optional)
City

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Country/region

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State

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ZIP code

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Additional details

Hope Bridge will deliver items to the family within 48 hours of receiving this form. For further information email brittany@hopebridgeohio.org


NOTE: CURRENTLY SERVING THOSE WHO LIVE IN STARK, SUMMIT, PORTAGE & CARROLL COUNTIES

Which county do you live in? (Please note: In order to effectively serve our families we are currently only able to deliver bags to those who reside in the below counties.)

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Full Address for Delivery:

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Type of Caregiver: (Check all that apply)

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Best way to contact Caregiver:

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Please list preferred contact information: (phone # and/or email)

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Agency licensed with/working with if foster family or kinship family (Put NA if not working with an agency)

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Is there an open DCFS case?

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Date the child(ren) arrived in your home (if placed out of home). **Please note: bags are intended to be delivered within 5 days of the child being placed in the home.

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How many child(ren) are in need of Comfort & Care items?

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Total number of people in your home:

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List NAME, AGE, GENDER, and SIZE for each child receiving a Comfort & Care Bag for pajamas, diapers/pull-ups, undergarments to the best of your knowledge. (Example: Jill -5 yr Female: size 5T clothes; Jamika 4 yo Female: size 3T clothes, 4T pull-ups)

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Child's ethnicity for hair care purposes:

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Please share any details you feel comfortable with about the family or child’s story. (Example: She was removed due to substance abuse, dad is not apart of the picture, came to us with only the clothes on her back.)

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Please list any food allergies in the home:

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I, as the Caregiver, understand that my address will be shared for delivery purposes only to receive the items requested. I understand that the items will be delivered by Hope Bridge Volunteers or through Amazon. Please write "I Agree" below.

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Is there anything else you would like us to know about how we can serve your family?

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How did you hear about us?

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We'd love to know who else is supporting you on your journey! Feel free to list your church, community group or other organizations you are involved with.

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