Regional request form

Thanks for visiting St Kilda Mums Rural and Regional Service.

To access our service, all social workers and Maternal and Child Health nurses must be registered with St Kilda Mums.

If you are not yet registered, please register as a regional social worker here prior to completing this form.

We are still working hard to help as many families as we can. Due to the current impact COVID is having on our staff and volunteers we are unable to operate at our regular capacity and have to reduce aspects of our service in the interim. Please access available brokerage or funding before placing this order.

Until further notice, we are only able to offer two large (waitlisted) items per order - this applies to cots, car restraints and prams. We apologise for any inconvenience while we try and meet the increasing demand in our community with fewer resources.

Please complete one form for each family you are requesting for, unless you are placing an order for bulk stock. In this instance, please add "bulk stock" in the "mother's or primary carers name" field.

For helpful hints on how to complete this form please click here.

For further assistance or for emergency requests, please contact the Regional Service Coordinator via email at regional@stkildamums.org

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

Your Details

Your name*

Your organisation*

Email*

Mobile number*

example: 0400111333

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 or primary carer's full name or reference (to prevent duplication of orders, for example: Jane Doe)*

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)*

Other disadvantages*

Is DHHS involved with this family/child?*

Has this family been affected adversely by COVID-19?*

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?*

How many children are in the family in total?*

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

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

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

Items Required

Cot with mattress: 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 and

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)

Single Pram

Stacker/Tandem Pram

Side by Side Double Pram

We try to match the best pram for the family, please indicate if they have a car or they rely on public transport and/or any details relevant for pram/stroller selection.

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

Specify the nappy sizes here

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.

Baby Front Carrier

Bath

Breast Feeding Kit (includes manual breast pump)

Breast Feeding Pillow

Bottles (only available once baby is born)

Bouncer

Change Mat

Coats

First Feeding Kit (utensils and equipment)

Formula (only available once baby is born)

Baby Food

Highchair

Cloth Nappies

Nappy Bag

Safety Kit (drawer/cupboard locks, power point covers etc)

Safety Gate

Sterilizer

Toiletries Packs: Baby or Child

Female Toiletries - Adult

Male Toiletries - Adult

Toy Bags and Playmats

Books and Craft Packs

Baby Wipes

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.

Size	Boy	Girl
UniPrem:
Prem (Size 00000)
0-3 m (Size 0000 - 000)
3-12 m (Size 00 - 0)
1-2
2-3
3-4
5-6
7-8
9-10
11-12
13-14
15-16

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. Please note shoe size does not correlate to child's age. (C = child, Y = youth)

Size	Boy	Girl
C3
C4
C5
C6
C7
C8
C9
C10
C11
C12
C13
Y1
Y2
Y3
Y4
Y5
Y6
Y7

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

Size	Boy	Girl	Unisex
Bassinet
Cot
Single Bed

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?*