Application If you prefer to mail your application, you can download the PDF version HERE.

CONTACT INFORMATION
Full Name :
Street Address :
City :
County :
State :
Zipcode :
Phone :
Email :

APPLICATION INFORMATION
Medical Coverage : Medicaid   OMCFH   Private Insurance   None
Currently Pregnant?:  Yes   No          If yes, due date: 
Family Size : Small (1-2)   Medium (3-4)  Large (5+)
Number of Children
(Not Including Pregnancy)
:
Age of Children :
Height & Weight of Children in Need of Car Seats :
Family Income
(Per Month)
:
Are you willing to be contacted by WV Healthy Start/HAPI Project & RFTS to discuss available services for a healthy pregnancy and/or healthy baby?:   Yes    No
How did you hear about this offer? :






Please provide us with your service provider's name and number. :
When will you need to begin using this car seat?:  
       2-4 Weeks   1-2 Months   2+ Months
Today's Date (m/d/yy) : //20
Due to overwhelming need and funding constraints, Buckle Your Baby for Life cannot supply car seats to all applicants.
ATTENTION: If you are chosen to receive a car seat, you will need to arrange to pick it up. Your application will expire after 30 days; you can reapply after that time. Only recipients will be contacted. We will only be distributing car seats 5 - 40 lbs.
 
 
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