Date: ____________________________

RESIDENT INTAKE STARTER KIT

Name of Family: __________________________________                        Unit#: _________________________

I have received the items listed below.  

ITEM	NUMBER RECEIVED	
Food Pack		
Beverly Pack (including dishes, pan, etc.)		
Sheets		
Blankets		
Pillows		
Pillow Case		
Towels		
Broom		
Mop		
Crib Pack		
Trash Can		
Other:		

I have also received the following items.  I understand that these items belong to (Facility) _____________________________ and are to be maintained in good condition and remain in the apartment or be returned to agency staff when I move.

ITEM	NUMBER RECEIVED	
Dining Room Table		
Dining room Table Chairs		
Coffee Table		
High Chair		
Crib		
Mattresses		
Bed Frames		
Bolsters		
Bedspreads		
Dresser		
Unit Key		
Mailbox Key		
Identification Card		
Other:		

Signature of Residents: ___________________________________                                Date:__________________________

Signature of Staff: _______________________________________                                Date: _________________________

Original:   Case File