Product Needs Form - Giving to the Nations Racine

Giving to the Nations

Healthy Essentials Pantry

Product List

To enable us to help you with personal, baby and home cleaning products you need, please complete this PRODUCT LIST below.

You can complete the online Product List below or download and return it to us (instructions are on the form).

Both the INTAKE FORM and the PRODUCT LIST must be completed if you need personal, baby or home cleaning products.

Downloads: Intake Form | Product List

Healthy Essentials Product List

PRODUCT LIST

Please complete this form if you would like help with personal, baby or home cleaning products.

Please understand, products requested are not guaranteed. We do everything we can to have all items available, unfortunately that is not always possible.

First Name

Last Name

Date

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

ADULT PERSONAL CARE ITEMS -- Please enter the number 1 for each item you are requesting.

Deordorant Male

Deordorant Female

Shampoo

Conditioner

Bar Soap

Hand Soap

Hand Sanitizer

Shaving Cream Male

Shaving Cream Female

Razors Male

Razors Female

Body Wash

Body Lotion

Adult Briefs (bladder/urine leaks) Male

Male Brief Size

Adult Briefs (bladder/urine leaks) Female

Female Brief Size

FEMININE HYGIENE PRODUCTS -- Please enter the number 1 for each item you are requesting.

Pantiliners

Pads

Tampons

DENTAL CARE ITEMS -- Please enter the number 1 for each item you are requesting.

Toothbrush Adult

Toothbrush Child

Toothpaste

Dental Floss

BABY PERSONAL CARE ITEMS -- Please enter the number 1 for each baby care item you are requesting, except diapers, choose diaper size.

Diaper Size-1st choice

Diaper Size-2nd choice

Diaper Size-3rd choice

Baby Wipes

Baby Ointment

Baby Wash (shampoo/bath)

Baby Lotion

HOUSEHOLD CLEANING PRODUCTS -- Please enter the number 1 for each item you are requesting.

Dishwashing Detergent

Multi-purpose Cleaner

Disinfecting Wipes

Trash Bags-13 Gallon

Paper Towels

Toilet Paper

Laundry Detergent

Dryer Sheets

Giving to the Nations - devoted to advancing the lives of others

Healthy Essentials Pantry

PRODUCT LIST

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