Request Form

If you are not yet registered, please register here before 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 Social Services Coordinator via email.

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

Your Details

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? *

Does this family identify as Aboriginal or Torres Strait Islander? *

What are the causes of disadvantage for this family? (you may select multiple items by holding down your Ctrl or command key)*

If you chose 'other', please detail in the notes field at the end of this form.

Does the family have a health care card? *

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

How many 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)*

What type of pram would you like to request? (please choose one) *

What car restraint(s) do they need? (you may select multiple items by holding down your Ctrl or command key) *

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)

What clothing bags do they need? (you may select multiple items by holding down your Ctrl or command key)

What sized linen or bedding do they need? (you may select multiple items by holding down your Ctrl or command key)*

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? *