PPE Data Summary

I Provider number 153106 acknowledge that I received the following amount of supplies:
0 Bleach	4 Toilet Paper
0 Disinfectant Wipes	0 Gloves
0 Hand Soap	35 Cloth Masks
6 Hand Sanitizer	35 Disposable Masks
10 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		16 years old
Caregiver’s Signature or Mark: ______________________________________________________________________________
Delivered on August 3, 2020 at 2:10 PM				Caregiver’s zipcode: 98108
Organization making the delivery: Sisters in Common