Tangible Item Delivery Receipt
Name
*
First Name
Last Name
Race
*
Black or African American
White or Caucasian
Asian
Native Hawaiian or Pacific Islander
American Indian or Alaskan Native
Unknown
Ethnicity
*
Hispanic
Non-Hispanic
Haitian
HMHB Program
*
Mahagony
Client Zip Code
*
Client City
*
Client Bus Pass #
Bus Pass Type
3 Day
7 Day
10 Day
31 Day
Gas Card #
Company Name & Amount:
Gift/Food Card #
Company Name & Amount:
Costco or Item(s) Requested and/or Delivered:
Welcome to the World Package Requested / Date of Delivery
Items Given
Rows
Child Name
Child Date of Birth
Diaper Size
Quantity
Other
A
B
C
D
Gender
*
Male
Female
Item Value (If not previously listed above)
Total value (If more than one item delivered)
Manager
Manager Approval:
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
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44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Staff
Staff Signature:
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
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47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Client
Participant's Signature:
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: