Supply Request 

For Douglas Co. Oregon residents only
*WHILE SUPPLIES LAST*
REQUESTS MAY TAKE 3-4 WEEKS TO PROCESS

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* 1. CONTACT  **IF NOT COMPLETE, REQUEST WILL NOT BE FILLED**

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* 2. PLEASE CHECK ONLY ONE (1)OF THE FOLLOWING:
DUE TO HIGH DEMAND PLACE ONLY ONE REQUEST PER FAMILY INCLUDING IMMEDIATE RELATIVES PLEASE.
REQUESTS FOR MULTIPLE SAFETY ITEMS WILL NOT BE FILLED

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* 3. Do you need diapers(Kirkland only)/Pull-Ups at this time? Please enter size 1 through 6 for diapers and 2t/3t, 3t/4t, 4t/5t Boy or Girl for pull-ups. Wipes are provided.

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* 4. SPECIAL CIRCUMSTANCES WE MAY NEED TO KNOW ABOUT.  Ex. TWINS NEED 2 CAR SEATS, PREEMIE BABY, ETC...

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* 5. Would you like information about any of the following Ucan programs?

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* 6. NAMES AND DATE 

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* 7. UPON ENTERING MY NAME AND DATE OR UPLOADING A SIGNATURE: I hereby release Healthy Start and UCAN-WIC from any and all liability, including, but not limited to, personal injuries (including death) to myself and others, property losses and damage caused by, or in connection with, mentioned above health and safety items, and agree to indemnify and hold harmless Healthy Start and UCAN-WIC. I assume any risk of harm or injury—to myself and others—which might occur as a result of improper usage or recall of the health and safety items, and release Healthy Start and UCAN-WIC from all liability, costs, and damages which might arise from the items.

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* 8. ONLY SIGN & DATE WHEN YOU  PICK-UP

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