Agency Request Form - Bloomington, IL - The Forgotten Initiative

Select Your Agency*

DCFS workers -- please note, if filling this form out via your DCFS computer, the form may not go through due to agency firewalls. Once the form is filled out, if you do not receive a confirmation email, please fill out the form via your phone.

Your Name*

First Last

Your Cell Phone Number*

Your Office Phone Number*

Your Email Address*

What need(s) do you have?

Check all that apply*

With each 'need' you choose, questions will drop-down below for follow-up information to be shared.

Tangibles: Journey Bags and Resources
First Response: Helps provide immediate needs you may have (mattress & bed, bedding, car seat, etc.)
Worker Appreciation Efforts: Coffee, flowers, food, notes of encouragement and projects all geared to show agency workers they are not alone.

Tangibles

Please mark any of the Tangibles that you are currently in need of:*

Journey Bags - Diaper bags, backpacks, or duffel bags with personal & comfort items for children in foster care to call their own
Infant and Toddler Care Items - Basic care items needed commonly during transition times
Home Cleaning Kits - Cleaning supplies to help vulnerable adults or foster parents care for or welcome in children

Journey Bags

Diaper bags, backpacks, or duffel bags with personal & comfort items for children in foster care to call their own

What size Journey Bags do you need in GIRL bags?*

What size Journey Bags do you need in BOY bags?*

Infant and Toddler Care Items

Basic care items commonly needed during transition times.

What Infant and Toddler Care Items are you requesting?*

What size diapers are needed?*

What size Pull-Ups are needed?*

Tangible Needs | Additional Information

Please indicate any details for the needed Tangible items you are requesting.

First Response

Helps provide immediate needs you may have (mattress & bed, bedding, car seat, etc.)

Desired deadline for the need to be met:*

48 hours
4 days
1 week
2 weeks

Urgency Level

!!!: Absolutely need this by the desired deadline
!!: Prefer by the desired deadline, but there is wiggle room
!: Flexible on the date, it will be a blessing whenever we can get it

Client Name*

First

Which best describes your client(s)?*

How many parents are in the home?*

1 parent household
2 parent household

What is the expected reunification/move-in date?*

Please list other resources you have explored to meet this need:*

Description of Need: (please select the item(s) you need)*

Car Seat(s)
Bed(s)
Bedding
Portable Dresser

First Response | Car Seat Specifics

What kind of car seat(s) are needed?*

Infant Car Seat (5-22 lbs.)
Convertible Car Seat (5-22 lbs. rear-facing OR 20-65 lbs. forward-facing)
Boost Car Seat (40-65+ lbs.)

Quantity of Infant Car Seats Needed:*

Quantity of Convertible Car Seats Needed:*

Quantity of Booster Car Seats Needed:*

First Response | Bed(s) & Mattress(s) Specifics

What bed size(s) is/are needed?*

Crib
Twin Bed
Bunk Bed - Twin (Please Note: Bunk beds are to only be requested for children 4 years and older.)

Quantity of Cribs Needed:*

Quantity of Twin Beds Needed:*

Quantity of Bunk Beds (twin) Needed:*

What is needed for the bed(s) you selected?*

Bed Frame
Mattress

Provide additional details if you have specific needs for the items selected.

First Response | Bedding Specifics

What size bedding is needed?*

Crib
Toddler Bed
Twin Bed
Bunk Bed - Twin

What bedding is needed for the bed(s) selected?*

Pillow
Sheets
Blanket/Comforter

Provide additional details if you have specific needs for the items selected.

Please give us more information about each individual needing bedding.*

(Click (+) to add more rows/individuals)

Gender	Size Bedding Requested	Favorite Color	Favorite Characters/Interests

First Response & Tangible Need Pick Up Information

Note: We are unable to fulfill requests between December 24-January 2. Any requests made during that timeframe will be fulfilled beginning on January 3.

When would you like to pick-up the items?*

Please note, only agency representative are able to pick-up the requested tangibles. Clients are not able to pick-up.

Worker Appreciation Efforts

Coffee, flowers, food, notes of encouragement and projects all geared to show agency workers they are not alone.

Please indicate what kinds of treats or encouragement the workers at your agency enjoy.*

Name

This field is for validation purposes and should be left unchanged.