Please return completed form by email to:
info@projectplayinc.org

Child Information

Name _____________________________ Age _____ Gender (optional) ______________ 

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: ____________________

By mail to:

​6658 E. 10th St., Indianapolis, IN 46219 or

PO Box 349, Nashville, IN 47448

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? ____________________________________________________________________________

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?

__________________________________________________________________________________________________________________