Client Requests

Partner Organization*

Case Manager/Social Worker Name*

Email*

Contact Number*

Initials of Client Receiving Items

Gender

Male

Female

N/A

County

Has this client received items from LAHMBS before?

Yes

No

Please Select all that apply

None

Socks

Hats

Gloves

Wipes

Hygiene items

Bottles

Crib sheets

Blankets

Pack-n-play

Highchair

Stroller

Other (Include size)

Arer there any other specific requests or information you would like to share

LAHMB's does not, by policy or practice, discriminate against a person or group on the basis of race, color, religion, gender, sexual orientation, national origin, age, disability, gender identity and expression, marital or military status, or based on any individual’s status in any group or class protected by applicable federal, state, or local law

717-545-5200 ext. 14

thelahmbs@gmail.com

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