Client Application Form Client Application Apply for The Free Store Services Step 1 of 7 14% Welcome to the Client Application form The Free Store provides furniture and household goods to individuals and families that are being served and supported by other agencies. We don’t provide our services to individuals that are not supported by an agency. This form is to be filled out by an employee of the agency that is supporting the person in need of household goods. Throughout this form, the employee of the agency will be referred to as the advocate. If your agency does not already have a relationship with The Free Store call 515-282-3733 or email info.thefreestore@gmail.com so we can explain how our processes work. Agencies working with us include county assistance programs, faith-based organizations, shelters, emergency assistance, mental health services, veteran and disability programs and immigrant/refugee services Throughout this form, you will not be able to advance to the next page if the required information is not filled in. You will be given an error message by the entry that is not right. The error message will go away as soon as you fix the problem and click the “Next” button. When finished a completed client form will be e-mailed to you. Tell us about you and your agency. Agency(Required)< Choose Agency >ACCESSAging ResourcesBroadlawns Community ServicesCatholic CharitiesCIACCentral Iowa Shelter ServicesCFI–DVSCFI–NON-DVSCommunity Support AdvocatesDes Moines Public SchoolsDHSDepartment of Veterans AffairsDorothy’s HouseEyerly BallFaDSSInternational Rescue CommitteeIowa Homeless YouthJoppaLatinx Immigrants of IowaLUNALutheran Services in IowaMid Iowa Family Therapy ClinicMonsoonNISAA African Family ServicesOrchard PlaceVA Central IowaWest Des Moines SchoolsWomen at the WellYSS – AmesYSS – LighthouseOtherAgency Name(Required) Service Level and Fee Level Approved domestic violence agency Approved veteran, sex trafficking, public school or prisoner release agency Other agency Our level of service is different for approved Domestic Violence support agencies( DV ) than for others ( non-DV ). Make sure that you set this value correctly.Agency Contact Person or Advocate(Required) You are the person that we work with to put your client’s household together. You will accompany the client to our warehouse to choose items.Advocate Phone(Required)Advocate Email Address(Required) Tell us about your client!Client's Name(Required) First Last Maiden or other surname Birth Date(Required) Month Day Year Phone(Required)If client phone is not available, use the advocate phone number.Can we send text messages to the client? Yes No Delivery Address(Required) Street Address Address Line 2 City State IAAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Has the client used The Free Store before? Yes No When did they use the The Free Store?(Required) Month Day Year Tell us about the people that make up the client’s household.Describe the race of the family(Required) Caucasion African American Asian Hispanic Native American Other Choose whatever categories apply to the client’s family. Describe the family's adults(Required) Adult female Adult male Adult non-binary How many children?(Required) None One Two Three Four Five Six Seven Eight Nine Ten How many adult women are in the family?(Required) One Two Three Four Five How many adult men are in the family?(Required) One Two Three Four Five How many adult non-binary people are in the family?(Required) One Two Three Four Five Age – Child One(Required)BabyOne year oldTwo year oldThree year oldFour year oldFive year oldSix year oldSeven year oldEight year oldNine year oldTen year oldEleven year oldTwelve year oldThirteen year oldFourteen year oldFifteen year oldSixteen year oldSeventeen year oldAge – Child Two(Required)BabyOne year oldTwo year oldThree year oldFour year oldFive year oldSix year oldSeven year oldEight year oldNine year oldTen year oldEleven year oldTwelve year oldThirteen year oldFourteen year oldFifteen year oldSixteen year oldSeventeen year oldAge – Child Three(Required)BabyOne year oldTwo year oldThree year oldFour year oldFive year oldSix year oldSeven year oldEight year oldNine year oldTen year oldEleven year oldTwelve year oldThirteen year oldFourteen year oldFifteen year oldSixteen year oldSeventeen year oldAge – Child Four(Required)BabyOne year oldTwo year oldThree year oldFour year oldFive year oldSix year oldSeven year oldEight year oldNine year oldTen year oldEleven year oldTwelve year oldThirteen year oldFourteen year oldFifteen year oldSixteen year oldSeventeen year oldAge – Child Five(Required)BabyOne year oldTwo year oldThree year oldFour year oldFive year oldSix year oldSeven year oldEight year oldNine year oldTen year oldEleven year oldTwelve year oldThirteen year oldFourteen year oldFifteen year oldSixteen year oldSeventeen year oldAge – Child Six(Required)BabyOne year oldTwo year oldThree year oldFour year oldFive year oldSix year oldSeven year oldEight year oldNine year oldTen year oldEleven year oldTwelve year oldThirteen year oldFourteen year oldFifteen year oldSixteen year oldSeventeen year oldAge – Child Seven(Required)BabyOne year oldTwo year oldThree year oldFour year oldFive year oldSix year oldSeven year oldEight year oldNine year oldTen year oldEleven year oldTwelve year oldThirteen year oldFourteen year oldFifteen year oldSixteen year oldSeventeen year oldAge – Child Eight(Required)BabyOne year oldTwo year oldThree year oldFour year oldFive year oldSix year oldSeven year oldEight year oldNine year oldTen year oldEleven year oldTwelve year oldThirteen year oldFourteen year oldFifteen year oldSixteen year oldSeventeen year oldAge – Child NIne(Required)BabyOne year oldTwo year oldThree year oldFour year oldFive year oldSix year oldSeven year oldEight year oldNine year oldTen year oldEleven year oldTwelve year oldThirteen year oldFourteen year oldFifteen year oldSixteen year oldSeventeen year oldAge – Child Ten(Required)BabyOne year oldTwo year oldThree year oldFour year oldFive year oldSix year oldSeven year oldEight year oldNine year oldTen year oldEleven year oldTwelve year oldThirteen year oldFourteen year oldFifteen year oldSixteen year oldSeventeen year old Tell us about the client’s new residence.This information is as important for you and your client as it is for us. We will all be disappointed if you are provided with a new household, only to find out that you can’t get it into your new place. Before choosing the stuff you want from us, determine if you even have room for it. Move In Date Month Day Year We don’t want to provide a set of household goods until you have a place to put them.Apartment or House Apartment House Apartment complex name Building Floor First Floor Second Floor Third Floor Fourth Floor Fifth Floor Higher than Fifth Floor How will you get up to the apartment? Stairs Elevator Sharp corners on Stairs Yes No Total Number of Rooms One Two Three Four Five Six Seven Eight Nine Number of Bedrooms One Two Three Four Five Six Living Room Yes No Dining Room Yes No It’s time to tell us what you need! We can’t guarantee every needed item is available. Some items are limited by availability; some by family size. Only request what you really need. Occasionally, an advocate or client will be extremely disappointed when they don’t get everything that they want. We understand that the FreeStore concept will not meet every organization’s needs. If you absolutely have to get everything that you are applying for, we suggest that you seek your household goods from other sources. Living RoomLiving Room Couch or Loveseat Living Room Chair Small Table Coffee Table Bookcase Desk TV Couch or Loveseat Option(Required) Couch Loveseat Baby and ChildrenBaby and Children Changing table Play Pen Youth Bed Youth Chair Stroller Crib Youth\Crib Bedding KitchenKitchen Table Chairs Bar Stools Pan Set Dish Set Microwave Toaster/Oven Mixer Blender Coffee Pot Crock Pot The pan set is a kit that includes a pan, a pot, and some utensils. The dish set is a kit that consists of large plates, small plates, bowls, cups, drinking glasses, and flatware. Remember, we limit selection to 3 small appliances (microwave, toaster/oven, mixer, blender, coffee pot, or crockpot).Chairs(Required) None One Two Three Four Five Six Bar Stools None One Two Three Four Five Six BedroomConsider the size of the residence and stair case when choosing a preferred bed size. Queen size mattresses often cannot be carried up stairs or around corners. We will do our best to provide an appropriate bed from our available supply at the time of appointment. Not sure what size you want? Check out this guide.Bedroom Queen Mattresses Full Mattresses Twin Mattresses Bunk Set Dresser Sheet Set Blanket Pillow Mattress Cover Comforter / Bed Spread Queen Mattress One Two Three Four Five Six Queen Bed Frame None One Two Three Four Five Six Full Mattress One Two Three Four Five Six Full Bed Frame None One Two Three Four Five Six Twin Mattress One Two Three Four Five Six Twin Bed Frame None One Two Three Four Five Six Bunk Set One Two Three Four Five Six Dresser None One Two Three Four Five Six Sheet Set None One Two Three Four Five Six Seven Eight Nine Ten We provide kits consisting of fitted sheet, flat sheet, and pillow cases. We’ll choose the right sizes for you when you visit the warehouse. One set per bed. If there are children and we have sufficient inventory, we will allow a second set per every 2 childrenBlankets None One Two Three Four Five Six Seven Eight Nine Ten We’ll choose the right sizes for you when you visit the warehouse.Pillows None One Two Three Four Five Six Seven Eight Nine Ten Comforter / Bed Spread None One Two Three Four Five Six Seven Eight Nine Ten Mattress Cover None One Two Three Four Five Six Seven Eight Nine Ten BathTowel Set None One Two Three Four Five Six Seven Eight Nine Ten A towel set consists of two bath towels, two hand towels, and two wash cloths. Shower Curtain Shower curtain MiscellaneousMiscellaneous Iron Ironing Board Radio Vacuum Cleaner Floor Lamp Table Lamp Storage Unit Large Rug Small Rug Fan Space Heater Kit of Cleaning supplies Signature Page It is important for you and your client to understand our process and rules, and agree to abide by them. Acknowledgement of FreeStore Guidelines(Required)Freestore Guidelines for Domestic Violence Advocates and Clients(Approved agencies include CFI-DVS, CIAC, ACCESS, LUNA, Monsoon, Nissa) FreeStore volunteers will move the items for Des Moines area clients into a FreeStore truck at the warehouse and will then move the items into their new home. The client can bring their own truck and help. Non-Des Moines area clients will need to provide their own truck and help.The warehouse loading area is next to the JuJitsu Academy, which is at 841 11th St in Des Moines: east on Crocker from Keo Way, then south on 11 th Street. We are the second building in the block.It is the responsibility of the agency’s representative to assure that the client treats the volunteers with respect. We reserve the right to refuse to serve any family who does not treat the FreeStore volunteer (the Greeter) with respect. We serve all qualified clients and do not discriminate on the basis of race, color, ethnicity, sex, sexual orientation or physical or mental disability.We may limit the number of times per month an agency may send us clients. We limit our services to advocates/agencies/ churches that have ongoing relationships with the families they want to sponsor. We reserve the right to refuse service to any person, advocate, or agency we feel does not meet the intent of our requirements.Normally, only the advocate and the client are allowed to go “shopping” with the Greeter. Other helpers are to remain in the front of the warehouse except when moving/loading furniture. We will only give items to a family who already has a house, condo, duplex, apartment, etc. We DO NOT give items that will be moved into a temporary place until the family has found housing. With few exceptions, clients are only allowed to use the FreeStore once. If a second trip is allowed it cannot be within 5 years of the first service or through an exception made by the advocate with the FreeStore. Finally, the Greeter is a volunteer and is at the warehouse to serve the advocate and client by appointment. The client must notify the advocate or Greeter in advance if the appointment cannot be met. If a client cancels twice, her/his request may not be served. I have read and understand The FreeStore Guidelines.How will household goods be transferred from The Free Store warehouse to the client's home?(Required) The Free Store will transport household goods to the client’s home in the DM metro. The client and advocate will provide their own transportation for household goods. Is the client going to come to the warehouse to select their items? Yes No How will client get to the warehouse?(Required)How will client get home from the warehouse?(Required)Type your initials in boxes below to signify you understand that The Free Store is an independent non-profit, run entirely by volunteers and that you will treat volunteers ( greeters, loaders, and drivers ) with respect and understand that the volunteer serving you has final say on any conflicts or decisions.Client Initials(Required) Advocate Initials(Required) Questions, Comments, ConcernsHiddenFee only HiddenAdvocate Notification Message HiddenScheduler Notification Message Hiddenguidelines HiddenSchedulerEmail HiddenBackupSchedulerEmail Δ
