Name ____________________________ Phone _________________ Email _________________________
Address ___________________________ City _______________ State _____ Zip Code ____________
Relationship to child ________________________ Primary language spoken in home __________________________
This information is NOT required. It only helps us ensure that we are serving a diverse group of families and targeting our efforts accordingly.
Child’s Ethnicity origin (or Race) ___________________
Highest completed education level in household: ___ No schooling completed ___ Some high school ___ Trade/Technical/Vocational training ___Associate’s degree ___ Bachelor’s degree ___ Master’s degree ___Professional degree ___Doctorate degree
Annual household income: ___ <$25,000 ___ $25,000-$50,000 ___ $50,000-$100,000 ___ $100,000+
Household composition: ___ Single parent __ Married parents ___Foster home __ Grandparents ___ Other: __________________
How did you hear about Project Play? ____________________________________________________________________________
Name _____________________________ Age _____ Gender (optional) ______________
Please return completed form by email to:
By mail to:
6658 E. 10th St., Indianapolis, IN 46219 or
PO Box 349, Nashville, IN 47448
Is the child considered to be typically developing? Yes No
If no, please elaborate. ________________________________________________________________________________________
Has the child received any diagnosis(es) that affect his or her play? ________________________________________________________
Has it been recommended that the child increase or engage in any specific play style (i.e. imaginative play, cooperative play)?
What was the main reason for seeking a Project Play donation for this child? _________________________________________________
Is there other information pertaining to the child that we should know in order to make the best toy selections for him or her?
How many children are being referred in this family or group? ____ This form is for child number ____ of ___ in family or group.
County: __ Marion __ Brown __ Hancock __ Monroe __ Johnson __ Other: ____________________