I Provider number 153125
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0 Bleach | 1 Toilet Paper |
1 Disinfectant Wipes | 2 Gloves |
1 Hand Soap | 0Cloth Masks |
1 Hand Sanitizer | 2 Disposable Masks |
1 Paper Towels | 0 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 | |||||||
Caregiver’s Signature or Mark: ______________________________________________________________________________ |
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Delivered on August 3, 2020 at 2:10 PM |
Caregiver’s zipcode: 98002 |
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Organization making the delivery: Sisters in Common |