Boxes of Basics · Boxes of Basics Referral Form

Referral Contact

This section is information about the person making the referral. You will be our main point of contact. Boxes of Basics does not deliver directly to children.

Your Name

*

First Name

Last Name

Your School/Organization Name

*

Your Title

*

Your Email

*

Verify Email

*

Your Phone Number

*

Where would you like to receive your Boxes of Basics?

*

Boxes of Basics are typically ready for pick up or delivery two weeks from the request date. As we are primarily a volunteer-run organization, picking up your boxes is preferred. If you cannot pick up, we will arrange delivery. Box deliveries made to schools are dropped off at the front office.

The Address Where Boxes Should be Delivered

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Child 1

Child's Name (please include first name and last initial)

*

First Name

Last Name

Child's Gender

*

Female

Male

Non-Binary

Child's Age

*

Child's Current Grade Level

*

Child's Race/Ethnicity

*

This information is used for data collection only.

Asian

Black

Hispanic/Latino

White

Other

Multiple

Where does the child live?

*

City of Manassas

City of Manassas Park

Prince William County

Fauquier County

Zip Code

*

Is this child eligible for free or reduced lunch at their school?

*

Yes

No

Is this child experiencing homelessness as defined by the McKinney Vento Assistance Act?

*

The McKinney-Vento Homeless Assistance Act defines homelessness as lacking a fixed, regular, and adequate nighttime residence, including those who are sharing the housing of others due to loss of housing, economic hardship, or a similar reason; staying in motels, trailer parks, or camp grounds due to the lack of an adequate alternative; staying in shelters or transitional housing; or sleeping in cars, parks, abandoned buildings, substandard housing, or similar settings.

Yes

No

What Does This Child Need?

Seasonal Wardrobe

*

Boxes of Basics stocks kids' clothes from newborn to a child's size 16. Wardrobes includes school and play clothes, layering pieces, pajamas, socks and underwear. IF THE CHILD YOU ARE REFERRING WEARS AN ADULT SIZE, PLEASE ANSWER NO.

Yes

No

Sneakers

*

Yes

No

Weather Appropriate Coat

*

Yes

No

Child's Clothing Size

Child's Shoe Size

We do our best to accommodate shoe size requests, but we can't guarantee above a kid's size 6.

Child's Jacket Size

Child's Preferences/ Favorites

*

Preferences, special situations, particular interests, favorite colors, etc. Help us choose the best clothing for this child!

Child's Circumstances

*

Please tell us about the child's circumstances. Why are you referring this child to Boxes of Basics?

Child 2

2 Child's Name (please include first name and last initial)

First Name

Last Name

Child's Gender

Female

Male

Non-Binary

Child's Age

Child's Current Grade Level

Child's Race/Ethnicity

This information is used for data collection only.

Asian

Black

Hispanic/Latino

White

Other

Multiple

Where does the child live?

City of Manassas

City of Manassas Park

Prince William County

Fauquier County

Zip Code

Is this child eligible for free or reduced lunch at their school?

Yes

No

Is this child experiencing homelessness as defined by the McKinney Vento Assistance Act?

The McKinney-Vento Homeless Assistance Act defines homelessness as lacking a fixed, regular, and adequate nighttime residence, including those who are sharing the housing of others due to loss of housing, economic hardship, or a similar reason; staying in motels, trailer parks, or camp grounds due to the lack of an adequate alternative; staying in shelters or transitional housing; or sleeping in cars, parks, abandoned buildings, substandard housing, or similar settings.

Yes

No

What Does This Child Need?

Seasonal Wardrobe

Boxes of Basics stocks kids' clothes from newborn to a child's size 16. Wardrobes includes school and play clothes, layering pieces, pajamas, socks and underwear. IF THE CHILD YOU ARE REFERRING WEARS AN ADULT SIZE, PLEASE ANSWER NO.

Yes

No

Sneakers

Yes

No

Weather Appropriate Coat

Yes

No

Child's Clothing Size

Child's Shoe Size

We do our best to accommodate shoe size requests, but we can't guarantee above a kid's size 6.

Child's Jacket Size

Child's Preferences/ Favorites

Preferences, special situations, particular interests, favorite colors, etc. Help us choose the best clothing for this child!

Child's Circumstances

Please tell us about the child's circumstances. Why are you referring this child to Boxes of Basics?

Child 3

3 Child's Name (please include first name and last initial)

First Name

Last Name

Child's Gender

Female

Male

Non-Binary

Child's Age

Child's Current Grade Level

Child's Race/Ethnicity

This information is used for data collection only.

Asian

Black

Hispanic/Latino

White

Other

Multiple

Where does the child live?

City of Manassas

City of Manassas Park

Prince William County

Fauquier County

Zip Code

Is this child eligible for free or reduced lunch at their school?

Yes

No

Is this child experiencing homelessness as defined by the McKinney Vento Assistance Act?

The McKinney-Vento Homeless Assistance Act defines homelessness as lacking a fixed, regular, and adequate nighttime residence, including those who are sharing the housing of others due to loss of housing, economic hardship, or a similar reason; staying in motels, trailer parks, or camp grounds due to the lack of an adequate alternative; staying in shelters or transitional housing; or sleeping in cars, parks, abandoned buildings, substandard housing, or similar settings.

Yes

No

What Does This Child Need?

Seasonal Wardrobe

Boxes of Basics stocks kids' clothes from newborn to a child's size 16. Wardrobes includes school and play clothes, layering pieces, pajamas, socks and underwear. IF THE CHILD YOU ARE REFERRING WEARS AN ADULT SIZE, PLEASE ANSWER NO.

Yes

No

Sneakers

Yes

No

Weather Appropriate Coat

Yes

No

Child's Clothing Size

Child's Shoe Size

We do our best to accommodate shoe size requests, but we can't guarantee them above a kid's size 6.

Child's Jacket Size

Child's Preferences/ Favorites

Preferences, special situations, particular interests, favorite colors, etc. Help us choose the best clothing for this child!

Child's Circumstances

Please tell us about the child's circumstances. Why are you referring this child to Boxes of Basics?

Child 4

4 Child's Name (please include first name and last initial)

First Name

Last Name

Child's Gender

Female

Male

Non-Binary

Child's Age

Child's Current Grade Level

Child's Race/Ethnicity

This information is used for data collection only.

Asian

Black

Hispanic/Latino

White

Other

Multiple

Where does the child live?

City of Manassas

City of Manassas Park

Prince William County

Fauquier County

Zip Code

Is this child eligible for free or reduced lunch at their school?

Yes

No

Is this child experiencing homelessness as defined by the McKinney Vento Assistance Act?

The McKinney-Vento Homeless Assistance Act defines homelessness as lacking a fixed, regular, and adequate nighttime residence, including those who are sharing the housing of others due to loss of housing, economic hardship, or a similar reason; staying in motels, trailer parks, or camp grounds due to the lack of an adequate alternative; staying in shelters or transitional housing; or sleeping in cars, parks, abandoned buildings, substandard housing, or similar settings.

Yes

No

What Does This Child Need?

Seasonal Wardrobe

Boxes of Basics stocks kids' clothes from newborn to a child's size 16. Wardrobes includes school and play clothes, layering pieces, pajamas, socks and underwear. IF THE CHILD YOU ARE REFERRING WEARS AN ADULT SIZE, PLEASE ANSWER NO.

Yes

No

Sneakers

Yes

No

Weather Appropriate Coat

Yes

No

Child's Clothing Size

Shoe Size

We do our best to accommodate shoe size requests, but we can't guarantee them above a kid's size 6.

Jacket Size

Child's Preferences/ Favorites

Preferences, special situations, particular interests, favorite colors, etc. Help us choose the best clothing for this child!

Child's Circumstances

Please tell us about the child's circumstances. Why are you referring this child to Boxes of Basics?

Child 5

5 Child's Name (please include first name and last initial)

First Name

Last Name

Child's Gender

Female

Male

Non-Binary

Child's Age

Child's Current Grade Level

Child's Race/Ethnicity

This information is used for data collection only.

Asian

Black

Hispanic/Latino

White

Other

Multiple

Where does the child live?

City of Manassas

City of Manassas Park

Prince William County

Fauquier County

Zip Code

Is this child eligible for free or reduced lunch at their school?

Yes

No

Is this child experiencing homelessness as defined by the McKinney Vento Assistance Act?

The McKinney-Vento Homeless Assistance Act defines homelessness as lacking a fixed, regular, and adequate nighttime residence, including those who are sharing the housing of others due to loss of housing, economic hardship, or a similar reason; staying in motels, trailer parks, or camp grounds due to the lack of an adequate alternative; staying in shelters or transitional housing; or sleeping in cars, parks, abandoned buildings, substandard housing, or similar settings.

Yes

No

What Does This Child Need?

Seasonal Wardrobe

Boxes of Basics stocks kids' clothes from newborn to a child's size 16. Wardrobes includes school and play clothes, layering pieces, pajamas, socks and underwear. IF THE CHILD YOU ARE REFERRING WEARS AN ADULT SIZE, PLEASE ANSWER NO.

Yes

No

Sneakers

Yes

No

Weather Appropriate Coat

Yes

No

Clothing Size

Child's Shoe Size

We do our best to accommodate shoe size requests, but we can't guarantee them above a kid's size 6.

Child's Jacket Size

Child's Preferences/ Favorites

Preferences, special situations, particular interests, favorite colors, etc. Help us choose the best clothing for this child!

Child's Circumstances

Please tell us about the child's circumstances. Why are you referring this child to Boxes of Basics?

Child 6

6 Child's Name (please include first name and last initial)

First Name

Last Name

Child's Gender

Female

Male

Non-Binary

Child's Age

Child's Current Grade Level

Child's Race/Ethnicity

This information is used for data collection only.

Asian

Black

Hispanic/Latino

White

Other

Multiple

Where does the child live?

City of Manassas

City of Manassas Park

Prince William County

Fauquier County

Zip Code

Is this child eligible for free or reduced lunch at their school?

Yes

No

Is this child experiencing homelessness as defined by the McKinney Vento Assistance Act?

The McKinney-Vento Homeless Assistance Act defines homelessness as lacking a fixed, regular, and adequate nighttime residence, including those who are sharing the housing of others due to loss of housing, economic hardship, or a similar reason; staying in motels, trailer parks, or camp grounds due to the lack of an adequate alternative; staying in shelters or transitional housing; or sleeping in cars, parks, abandoned buildings, substandard housing, or similar settings.

Yes

No

What Does This Child Need?

Seasonal Wardrobe

Boxes of Basics stocks kids' clothes from newborn to a child's size 16. Wardrobes includes school and play clothes, layering pieces, pajamas, socks and underwear. IF THE CHILD YOU ARE REFERRING WEARS AN ADULT SIZE, PLEASE ANSWER NO.

Yes

No

Sneakers

Yes

No

Weather Appropriate Coat

Yes

No

Child's Clothing Size

Child's Shoe Size

We do our best to accommodate shoe size requests, but we can't guarantee them above a kid's size 6.

Child's Jacket Size

Child's Preferences/ Favorites

Preferences, special situations, particular interests, favorite colors, etc. Help us choose the best clothing for this child!

Child's Circumstances

Please tell us about the child's circumstances. Why are you referring this child to Boxes of Basics?

Name

First Name

Last Name