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 caseworker 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 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 *:           


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, the mother’s name is preferred)*
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)*

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

 

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. 

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

 

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

 Cot Boy:   Bassinet Boy: 
 Cot Girl:   Bassinet Girl: 
 Cot Unisex:   Bassinet Unisex: 

 
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? *