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PPE Data Summary

I Provider number 153116
acknowledge that I received the following amount of supplies:

1 Bleach 0 Toilet Paper
2 Disinfectant Wipes 2 Gloves
2 Hand Soap 0Cloth Masks
5 Hand Sanitizer 4 Disposable Masks
0 Paper Towels 1 No-Touch Thermometer
Child 01:

0 – 11 Months

12 – 23 Months

24 – 25 Months

36 – 47 Months

4 Years

5 Years

6+ Years

Child 02:

0 – 11 Months

12 – 23 Months

24 – 25 Months

36 – 47 Months

4 Years

5 Years

6+ Years

Child 03:

0 – 11 Months

12 – 23 Months

24 – 25 Months

36 – 47 Months

4 Years

5 Years

6+ Years

Child 04:

0 – 11 Months

12 – 23 Months

24 – 25 Months

36 – 47 Months

4 Years

5 Years

6+ Years

Additional children & their ages

Covid-Safety Bag/Box


Caregiver’s Signature or Mark: ______________________________________________________________________________

Delivered on August 3, 2020 at 2:10 PM

Caregiver’s zipcode:

98144

Organization making the delivery: Sisters in Common