Regional request form

Your Details

We will work with you to arrange delivery. Please provide delivery address (items can be delivered to the agency and never to the client):

Family Information

Mother's full name or reference (to prevent duplication of orders, the mother’s name is preferred)*
What Local Government Area does the family live in? * --None-- Alpine Shire Bass Coast Shire Borough of Queenscliffe City of Ballarat City of Banyule City of Bayside City of Boroondara City of Brimbank City of Casey City of Darebin City of Frankston City of Glen Eira City of Greater Bendigo City of Greater Dandenong City of Greater Geelong City of Greater Shepparton City of Hobsons Bay City of Hume City of Kingston City of Knox City of Latrobe City of Manningham City of Maribyrnong City of Maroondah City of Melbourne City of Monash City of Moonee Valley City of Moreland City of Port Phillip City of Stonnington City of Warrnambool City of Whitehorse City of Whittlesea City of Wodonga City of Wyndham City of Yarra Colac Otway Shire Corangamite Shire Golden Plains Shire Pyrenees Shire Rural City of Ararat Rural City of Benalla Rural City of Horsham Rural City of Mildura Rural City of Swan Hill Rural City of Wangaratta Shire of Baw Baw Shire of Buloke Shire of Campaspe Shire of Cardinia Shire of Central Goldfields Shire of East Gippsland Shire of Gannawarra Shire of Glenelg Shire of Hepburn Shire of Hindmarsh Shire of Indigo Shire of Loddon Shire of Macedon Ranges Shire of Mansfield Shire of Melton Shire of Mitchell Shire of Moira Shire of Moorabool Shire of Mornington Peninsula Shire of Mount Alexander Shire of Moyne Shire of Murrindindi Shire of Nillumbik Shire of Northern Grampians Shire of Southern Grampians Shire of Strathbogie Shire of Towong Shire of Wellington Shire of West Wimmera Shire of Yarra Ranges Shire of Yarriambiack South Gippsland Shire Surf Coast Shire
Does this family identify as Aboriginal or Torres Strait Islander? * --None-- Yes No
What are the causes of disadvantage for this family? (you may select multiple items by holding down your Ctrl or command key)* Disability Family Reunification Family Violence Foster or Emergency Care Homeless or at risk of homelessness Kinship Care Life controlling addiction Medical Mental Health Migrant, Refugee or Asylum Seeker Natural Disaster Single Parent Unemployment Young Parents Other
If you chose 'other', please detail in the notes field at the end of this form.
Does the family have a health care card? * --None-- Yes No
Is this family connected with other support services? If so, who?
What is the due date of the baby or the birth date of the youngest child? (Please write dd/mm/yyyy) *
Baby's gender? * --None-- Boy Girl Not known Twins (add detail in notes)
How many children are there in total in this family? (please include baby or babies due to be born) *
As of today how many children are younger than 12 months (including the one(s) due)? *
What the 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)* --None-- One Cot & Mattress Two Cots & Mattresses (Twins) One Bassinet (Only available for pick-up) Two Bassinets (Only available for pick-up) Not required
What type of pram would you like to request? (please choose one) * --None-- Single Double - Stacker or in-line Double - Side by side Triple Quad Not required
What car restraint(s) do they need? (you may select multiple items by holding down your Ctrl or command key) * Capsule - newborn to 6 months Reversible - newborn to 4 years Toddler - 12 months - 4 years Booster - Approx 4 yrs (14kg+) Not required
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) Baby Bjorn/Carriers Bath Breastfeeding Kit Bottles Only Bouncer/Rocker/Swing Breast or Maternity Pads Breastfeeding Pillows Change Mat Change Table First Food Kits Formula Highchair Nappies - Disposable Nappies - Cloth Nappy Bag Playpen Safety Gate Safety Kit Steriliser Toiletries Toys/Activity Mats/Books&Puzzle Bags Wipes Cot Mattress (please add dimensions in notes)
What clothing bags do they need? (you may select multiple items by holding down your Ctrl or command key) BNB-1 B1-2 B2-3 B3-4 B4-5 B5-6 B7-8 B9-10 B10-12 GNB-1 G1-2 G2-3 G3-4 G4-5 G5-6 G7-8 G9-10 G10-12 UniPrem Boy Prem Girl Prem not required
What sized linen or bedding do they need? (you may select multiple items by holding down your Ctrl or command key)* Bassinet Girl Cot Boy Cot Girl Bassinet Boy Cot Unisex Bassinet Unisex Not required
Do you have any further notes or comments to make about this request?

Please confirm that you agree with the terms of our Service Policy? * --None-- Yes