Regional request form

Your Details

Your name *:
Your organisation *
Email *
Mobile number *

Delivery will be either to your office or to a freight depot nearby. Please provide delivery address (items will never be delivered directly to your client)*:

Family Information

Mother's full name or reference (to prevent duplication of orders, for example: Jane Doe)*
What Local Government Area does the family reside in? * --None-- Alpine Shire Bass Coast Shire City of Greater Bendigo City of Greater Shepparton City of Latrobe City of Warrnambool City of Wodonga Corangamite 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 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 Mitchell Shire of Moira Shire of Moorabool Shire of Mount Alexander Shire of Moyne Shire of Murrindindi Shire of Northern Grampians Shire of Southern Grampians Shire of Strathbogie Shire of Towong Shire of Wellington Shire of West Wimmera Shire of Yarriambiack South Gippsland Shire
Does this family identify as Aboriginal or Torres Strait Islander? * --None-- Yes No
Does the family have a health care card? * --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 or Refugee or Asylum Seeker Natural Disaster Single Parent Unemployment Young Parents Other

You may select multiple items by holding down your Ctrl or command key. If you chose 'other', please detail it here

Is DHHS involved with this family/child?* --None-- Yes No Not Known

Items Required

Cot: Does the family require one? If so, please enter 1 here (2 for twins)

If the family has a cot in good condition that complies with the current regulation and only needs a mattress, please enter 1 here , specify the details of the cot on notes and specify the required mattress size here (length, width and height). You should find these measurements on the base of the cot.

Pram: Does the family require one? If so, please enter 1 next to the type (one pram only)

If the family needs a multiples pram please enter 1 and we will contact you to confirm the most suitable solution.
Triple: Quad:

Car Restraint: Does the family require one? If so, please enter 1 next to the type. If you need more than one car restraint (for siblings or multiples) please enter the relevant number next to the type.

Capsule (rear facing for infant):
Reversible (rear and front facing):
Toddler (front facing with harness):
Booster (front facing, no harness):

Nappies: If the family needs nappies, please enter the number of children you are requesting nappies for here and specify the sizes here . Note that wipes will be automatically allocated with any nappies provided.

Other Items: Please enter 1 next to the following items in case the family would need any. If they need more than one please enter the number but remember that many items come in packs or kits.

Clothes: If clothes are needed, please enter the number of clothing bags on the size required. Please note that clothing bags contain 80-100 items.

Shoes: If shoes are needed, please enter the number of packs on the size required, note that there are approximately 5 pairs of shoes per pack (C = child, Y = youth)

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

 
Do you have any further notes or comments to make about this request?

We will notify you via email when your request is due for delivery.  (If you, a colleague or volunteer from your agency would ever like to collect requested items directly from our HQ in St Kilda please email regional@stkildamums.org to confirm a date for collection).

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