Participant Referral Form "*" indicates required fields Date Of Referral* MM slash DD slash YYYY Participant Information Participant/Client Name*Street Address for Delivery*Address Line 2City*State*Zip Code*Phone*Email* Ethnicity* American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Have you or a member of your family served in the United States military? Self Family Member Age*Reason for Referral and Any Additional Important Information*Move In Date Move In Date MM slash DD slash YYYY Household Members Total Number Of Adults*Please enter a number from 0 to 10.Number of Females*Please enter a number from 0 to 10.Number of Trans Female*Number Of Males*Please enter a number from 0 to 10.Number of Trans Male*Number of Non-binary/Gender Fluid*Number Of Children Child #1 AgeChild #1 Gender Identity Male Female Trans Male Trans Female Non-Binary/Gender Fluid Child #2 AgeChild #2 Gender Identity Male Female Trans Male Trans Female Non-Binary/Gender Fluid Child #3 AgeChild #3 Gender Identity Male Female Trans Male Trans Female Non-Binary/Gender Fluid Child #4 AgeChild #4 Gender Identity Male Female Trans Male Trans Female Non-Binary/Gender Fluid Child #5 AgeChild #5 Gender Identity Male Female Trans Male Trans Female Non-Binary/Gender Fluid Add Additional ChildrenAdd Child #6 Add Child #6 Child #6 AgeChild #6 Gender Identity Male Female Trans Male Trans Female Non-Binary/Gender Fluid Add Child #7 Add Child #7 Child #7 AgeChild #7 Gender Identity Male Female Trans Male Trans Female Non-Binary/Gender Fluid Add Child #8 Add Child #8 Child #8 AgeChild #8 Gender Identity Male Female Trans Male Trans Female Non-Binary/Gender Fluid Agency Information Agency Name*Case Manager*(Must Meet Movers on Delivery Day)Phone*(Our movers will call this number. Please do not list your office number. List your mobile number.)Email* Who is paying furnishing fee?*Number of Twin Bed Packages Requested(One per person. - Package includes New Mattress, New Frame, New Pillow, New Bed Bug Protector, and Twin Bedding)Queen Bedding Yes No (Mattress not included – this is for those who already have beds.)Apartment or House Apartment House What Floor Is Apartment?Elevator Access Yes No Name of Apartment complexWaiverWaiver Agreement*1. Obtaining furniture from Furnish for Good is a once-in-a-lifetime opportunity. All furniture selections are limited to the inventory available the day of your visit. There may be limits on certain items that are often in short supply. 2. The household furnishings are used. Such household furnishings are provided “as is” and Furnish for Good makes no warranties or representations regarding their condition. 3. A volunteer staff member from Furnish for Good as well as my Case Manager will accompany me on the Furnish for Good premises and will guide me while making my selections. Furnish for Good’s movers will determine if your selections can physically be moved into your unit. For example, some larger items may not be suitable for a 3rd floor move. If this is the case, we will ask you to make another selection. 4. Once my appointment is finished, my selections are final. 5. I assume all risk of loss or injury related to or caused by the household furnishings once I have removed them from Furnish for Good premises. 6. I give permission for Furnish for Good to photograph me for use on social media, the Furnish for Good website or in other promotional materials. 7. I will not share the link for the Furnish for Good online store site. I, the case manager, have gone over this waiver with the participant and they understand conditions.Participant/Client Name*Date MM slash DD slash YYYY Case Manager Name*Date MM slash DD slash YYYY Additional NotesPhoneThis field is for validation purposes and should be left unchanged.
