Please return completed form by email to:
Name _____________________________ Age _____ Gender (optional) ______________
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: ____________________
By mail to:
6658 E. 10th St., Indianapolis, IN 46219 or
PO Box 349, Nashville, IN 47448
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? ____________________________________________________________________________
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?