STOREHOUSE REFERRAL FORM

This form is intended for our Partnering Agencies and the Huntington County School Corporation. If you are one of our partners, please take the time to fill out the information requested below so we can best serve your students. Thank you for taking the time to help your students and connect them with The Indiana Family Care Center! Together, we will continue to help Huntington County Residents Thrive!

If you have any questions about this form please call our office at 260-200-1155.

Reporting Person's Name

First Name

Last Name

Reporting Person's Email

Reporting Person's Phone Number

(###)

###

####

What School does the student attend?

Student's Name

First Name

Last Name

Student's Sex

This is used to provide appropriate items based on the student's needs.

Male

Female

Brief Description of the Student's Needs

Student's Underwear Size (If Applicable)

Student's Shirt Size (If Applicable)

Student's Pant Size (If Applicable)

Student's Shoe Size (If Applicable)

Student's Coat Size (If Applicable)

Other Physical Item Needs (If Applicable)

Dental Hygiene Kit

Female Hygiene Product Kit

Basic Hygiene Kit

Toilet Paper

School Supplies (List Specifics in the Short Description above)

Other