Buckle Your Baby For Life!

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?	:	TV Radio Newspaper Friend Service Provider Doctor/Medical Provider Other
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.