-Field Order Form- Household Information – HH Staff Submitting Request: Click or tap here to enter text.Date Submitted: Click or tap to enter a date.
Household	Zip Code:	Income Level: % of	Housing Status
Last Name:	Average Median	☐Literally Homeless (car, outside) ☐Imminent Risk Homeless ☐Fleeing Domestic Violence ☐Shelter/Motel Vouchers ☐Transitional Housing	☐Section 8 Voucher/ Project- Based ☐Subsidized Housing (Public, HUD) ☐Tax Credit (ARCH) ☐Market Rate Housing ☐Unknown
Click or tap here to enter text.	Click or tap here to enter text.	Income
CPID: Click or tap here to enter text.	HV # or Classroom: Click or tap here to enter text.	☐ < 30% AMI ☐ < 50% AMI ☐ < 80% AMI ☐ > 80% AMI ☐ Unknown
Primary language Spoken in HH	Benefits Received (check all that apply) ☐Medicaid/ Apple Health ☐SNAP- Food Stamps ☐WIC ☐Section 8/Subsidized Housing ☐TANF ☐SSI/SSDI/SSA ☐Unemployment Insurance ☐Veterans Benefits	Total # of People in Household: Click or tap here to enter text.
☐English ☐Arabic ☐Cambodian/Khmer ☐Chinese/Mandarin ☐Ethiopian/Amharic ☐Korean ☐Mam/Guatemalan ☐Russian	☐Somali ☐South Asian/ Hindi ☐Spanish ☐Ukrainian ☐Vietnamese ☐Other Non- English
Primary Caregiver:	Does Primary	Primary Caregiver has a Disability: ☐Yes ☐No	Caregiver	Does the
Caregiver	Employment	vehicle
☐Single-Parent	Identify as	Status:	have both
Household ☐Two-Parent Household ☐Foster Parent ☐Grandparent/Relative ☐Other	LGBTQ+? ☐Yes ☐No	☐Full-Time ☐Part-Time ☐Unemployed ☐Unknown	lap and shoulder seatbelts? ☐Yes ☐No ☐Other

By providing this information I acknowledge that I have given permission to have this information entered into the secure EBC Ordering System as it is required to complete this order. Click or tap here to enter text. (Caregiver Initials)
Disclaimer: Data will be used for EBC internal use only; all information will be kept confidential.

-Field Order Form- Recipient Information
NOTE: Please update height, weight, clothing size and shoe size on monthly basis.
Recipient’s Name: Click or tap here to enter text. CPID: Click or tap here to enter text.	Birthdate/Due Date: Click or tap to enter a date. Month/Year	Gender: ☐Male ☐Female ☐Unknown	Recipient Type ☐Child ☐Expectant Mom or Postpartum
Height in Inches Click or tap here to enter text.	Weight in Lbs. Click or tap here to enter text.	Clothing Size: Click or tap here to enter text.	Shoe Size: Click or tap here to enter text.	Shoe Width: ☐Medium ☐Wide ☐Narrow
Clothing Sizes- Children: ☐Preemie ☐0-3m ☐3-6m ☐6-9m ☐12m ☐18m, ☐24m/2T ☐3T ☐4T ☐5/5T ☐6 ☐7 ☐8 ☐10 ☐12 ☐14 Maternity: ☐0 ☐2 ☐4 ☐6 ☐8 ☐10 ☐12 ☐14 ☐16 ☐18 ☐1XL ☐2XL ☐3XL
Shoe Sizes- Child: ☐0 ☐1 ☐2 ☐3 ☐4 ☐5 ☐6 ☐7 ☐8 ☐9 ☐10 ☐11 ☐12 ☐13 Youth: ☐1 ☐2 ☐3 ☐4 ☐5 ☐6 ☐7 Adult: ☐8 ☐9 ☐10 ☐11
Demographics
Race/Ethnicity:
☐American Indian/ Alaskan- Native ☐Asian ☐Asian Indian ☐Chinese	☐Filipino ☐Japanese ☐Korean ☐Vietnamese ☐Hispanic/ Latino	☐Cuban/ Puerto Rican ☐Mexican/Mexican American/Chicano ☐Black/ African-American ☐Biracial (Black-White) ☐Ethiopian ☐Somali	☐Native Hawaiian/Pacific Islander ☐Samoan ☐Multiracial ☐White Caucasian ☐Unknown
English Proficiency: ☐Low (Limited) ☐Medium ☐High	Refugee/ Immigrant ☐Yes ☐No ☐Unknown	Military Service: ☐No Military Service ☐Child of Parent in Active Service ☐Parent Military Service (past or present) ☐Partner of Person in Active Military Service ☐Unknown	Recipient has a Disability: ☐Yes ☐No ☐Unknown
By providing this information I acknowledge that I have given permission to have this information entered into the secure EBC Ordering System as it is required to complete this order. Click or tap here to enter text.(Caregiver Initials) Disclaimer: Data will be used for EBC internal use only; all information will be kept confidential.

-Field Order Form- For Recurring Recipients
NOTE: Please update height, weight, clothing size and shoe size on monthly basis.
Household Last Name: Click or tap here to enter text.	Recipient’s Name: Click or tap here to enter text.	Gender: ☐Male ☐Female ☐Unknown
Height in Inches Click or tap here to enter text.	Weight in Lbs. Click or tap here to enter text.	Clothing Size*: Click or tap here to enter text.	Shoe Size**: Click or tap here to enter text.	Shoe Width: ☐Medium ☐Wide ☐Narrow
*Clothing Sizes- Children: Preemie, 0-3m, 3-6m, 6-9m, 12m, 18m, 24m/2T, 3T, 4T, 5/5T, 6, 7, 8, 10, 12, 14 Maternity: 0, 2, 4, 6, 8, 10, 12, 14, 16, 18, 1XL, 2XL, 3XL
**Shoe Sizes- Child: 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 Youth: 1, 2, 3, 4, 5, 6, 7 Adult: 8, 9, 10, 11
Items Requested
Name of Item Exactly how it appears on Order form	Comments	Quantity (only for ítems if it applies)
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Special Notes: Click or tap here to enter text.

By providing this information I acknowledge that I have given permission to have this information entered into the secure EBC Ordering System as it is required to complete this order.

(Caregiver Initials): Click or tap here to enter text.

Disclaimer: Data will be used for EBC internal use only; all information will be kept confidential.