Parent/Caretaker Information

Name ____________________________  Phone _________________  Email _________________________

Address ___________________________ City _______________ State _____ Zip Code ____________

Relationship to child ________________________ Primary language spoken in home __________________________

Demographic information

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? ____________________________________________________________________________

Child Information

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

Play information

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?


Delivery Information

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: ____________________