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CAREFREE KIDS
East Lothian

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Safety Equipment Referral

Parent / Carer Details

Name*

Surname*

Address*

Email*

Phone*

Child Details

Name*

Date of Birth*

Male / Female*

Male

Female

Details of Family Circumstances

Number of Children in Family under 16*

Family in Receipt of Benefits?*

Yes

No

One or More Members of Family in Employment?*

Yes

No

Single Parent Family?*

Yes

No

Other Relevant Details

Items Requested (please note that is dependant on funding being secured)*

Stairgate

Fireguard

Cot (with new mattress)

High Chair

Buggy

Safety Pack

Other

If 'other', please specify below

Equipment to be*

Collected from the Office

Delivered

Referrer Details

Name*

Phone*

Email*

Signature*

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Date*

Day

Month

Year

Please note that items are subject to availability

Registered SCIO: SC048734

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