Full Name*

Email*

(example@example.com)

Phone Number*

(example : 021xxxxxxx | 025xxxxxx | 027xxxxxx | 029xxxxxx)

Client Details

PARENTS FULL NAME (NOT CHILD'S NAME).*
(This will be kept confidential) This is important to us as we need to identify if this client has had an application from another organisation or repeat applications to us.

How many members are in this family?*

How many children is this order for?*

What ethnicity does this family identify as?*

Does the family require nappies?

Nappies

Please only select one size per child.

	Quantity required
Stage 1 - Newborn - 3 - 5 kgs
Stage 2 - Infant - 4 - 8 kgs
Stage 3 - Crawler - 6 - 11 kgs
Stage 4 - Toddler - 10 - 15 kgs
Stage 5 - Walker - 13 - 18 kgs
Stage 6 - Junior - 16+ kgs
Reusable cloth nappies

Are any other baby product essentials needed?

Baby Product Essentials

We can only give what's available but will try to fill your request.

	Quantity required
Baby Toiletry Pack
Mum Toiletry Pack
Mens Toiletry Pack
Breast Pads
Baby Wipes
Dummies
Baby Bottles (ONLY Newborn)
Baby Food (4 months - 12 months)
Feeding Items(sippy cup,baby bowl/plate,baby cutlery etc)
Breast Pump
Breast milk storage bags or containers
Burp cloths

Are any other bedding essentials needed?

Bedding Essentials

We can only give what's available but will try to fill your request.

	Quantity required
Sleep Sacks or Swaddles
Blankets - Below 2 years
Blankets - 3 Years +
Wraps and Muslins
Cot Bedding
Bassinet Bedding
Flannels and Baby Towel

Does the family require clothing for unborn babies or children under 2 years of age?

Size	Boy	Girl	Neutral
Premature (00000)
New born (0000)
0-3 months (000)
3 – 6 months (00)
6-12 months (0)
12-18 months (1)
18-24 months (2)

Does this family require clothing for these children?

Children's Clothing

Each size clothing pack will contain enough clothing for one child.

Size	Boy	Girl
3
4
5
6
7
8
9/10
11/12
13/14
15/16

Does the child need shoes?

Please note we might not be able to fulfil all sizes.

Please fill in the exact US shoe size required

Does the family require bigger items?

Bigger Items

Highchairs

Playmats

Bouncers

Are there any other items or details you would like to add to this request?

Have you met with your client previously and assessed their need. Can you confirm that they are deemed in hardship or the children are at risk.*

Is there any other feedback you would like to share with us? We would love to hear more about how our service helps you and your clients or anything you feel we can improve on.

Thank you for completing this application on behalf of your client.

Please note we may not be able to fulfil everything requested, as stock is subject to availability, but we will try our best.

We have specific procedures that need to be followed for our warehouse team to work efficiently. When you submit an application, you will get a confirmation of your order form. This needs to be kept and printed or saved via phone, to be shown to our team at pick up. Please also be aware that you or a colleague will need to manage the collection- at no point do we allow clients on site.

When your order is ready to be picked up, please email us to advise your preferred day and time of collection.

If you have any questions or queries, please contact Danielle via email, referrals@nurturingfamilies.nz

	Age(months)	Gender
Baby 1
Baby 2
Baby 3

	Years	Gender
Children 1
Children 2
Children 3
Children 4
Children 5
Children 6
Children 7
Children 8
Children 9
Children 10

Your Details

Client Details

Order Details

Baby details

Children details

Nappies

Baby Product Essentials

Bedding Essentials

Children's Clothing

Bigger Items