Individual Bundle-Filling Form (Internal Use Only) Date MM DD YYYY GIVING * If "event" or "grant", provide details below. Bundles Joyful Closet Event Grant INDIVIDUAL INFO Name/Primary Contact * First Name Last Name Email DEMOGRAPHICS Total # of Mother's Served * # Children Served: Age 0-1 * # Children Served: Age 2-4 * # Children Served: Age 5+ * Total # Children Served * TOTAL COUNT OF ITEMS Number * I attest on behalf of the agency named above: The children's gear received will not be sold or distributed to Agency staff members of the general public. The children sear received is specifically for the distribution or children tamilies served by the agency. Waiver of Lability: In consideration of the provision of the supplies provided by Bundles of Joy New York, Inc., Agency, on behalf of itself, himself or herself and its, his or her heirs, affiliates, successors and assigns, hereby (a) assumes the responsibility for ensuring that all Diapers and Baby supplies are in good condition and/or working order before distributing such items, (b) assumes all risk and responsibility for personal injuries, illnesses or other damages in connection with the distribution and use of such supplies, and (c) fully and irrevocably releases, holds harmless, discharges and covenants not to sue bundles of Joy and its past, present future board members, officers. emplovees. affiliates, agents, representatives and assigns from any and all iniuries. losses, claims, demands, damages, rights of action, or causes of action, present or future, whether known or unknown, accrued or unaccrued. resulting from. arisine out of, or as a consequence of Agency's distribution and use of such supplies by Recipient Agency and its clients, end users or other third parties * AGREE TO THE ABOVE BY ENTERING FULL NAME BELOW Bundle information submitted and uploaded to client database. Next-step: reach out to schedule bundle pick-up. Thank you!
