Client request form

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Debt Free Building

This form is to be filled out by a case worker or organization as we do not work directly with clients.

* Indicates required field

Person filling out this form *

First

Last

Case Worker *

First

Last

Person filling out this forms Phone Number *

Organization you are with *

Email for person filling out this form *

Is your organization signed up to partner with re:MADE? *

Yes No Not sure

Family receiving items *

First

Last

How many people in the household?

Adults *

Children [Please list ages] *

We may or may not have all of the items you are requesting - please list preferences.

Kitchen *

Table Chairs Bar Stools Plates Bowls Mugs Silverware Pots & Pans Coffee Pot Slow Cooker Toaster Cutting Board Kitchen Box [misc. kitchen items]

Bedroom *

Queen Bedding Double/Full Bedding Crib Bedding Toddler Bed Twin bed frame Twin Mattress Queen Bed Frame Queen Mattress Night stand Lamps Pillows Blankets Hamper

Family Room *

Coffee Table End Table Couch Loveseat Recliner/Side Chair Floor Lamp Lamp

Other *

Mens socks Womens socks Child socks Diapers [please list sizes below]

Bathroom *

Soap and Shampoos Feminine Products Towels Laundry Basket Shower Curtain Shower hooks

Other *

Desk Child desk Bookcase Trash Can

Clothing - list gender, size and item needed, if we have Bomba Socks available we will send *

Add any other specific items and sizes if needed. *

Comment *

Bring a truck or large vehicle for pickup, we can not hold items. Please confirm that pick up happened with your client, as your organization may be removed from availability if repeated pickups are not completed.

Pick up options: *

Client picking up Organization volunteer picking up Other

Date for Pick Up *

Submit

Come and visit us today at 13500 Old Seward Hwy, Anchorage, AK 99515 @2025 Anchorage re:MADE Store.

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