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.
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