Moms in Need

If you are a mom/mom-to-be in need of essential baby items, we can help.  Please complete the application and make sure to include a list of what you need.  We will review your application and basis of need, and do our best to provide you with what you seek.  Santa Clause has his little helpers, and now so do you!

Please fill out the following form to be considered for assistance.
Name:  
Address:  
E-mail:  
Telephone:  
Date of Birth:  
Baby’s date of birth (or due date):  
Marital status  
Are you receiving any State or Federal benefits?   Yes No
If Yes, what kind (WIC, food stamps, SSI, etc.)?  
Does your family help support you emotionally or financially?   Yes No
Where is your family?  
Does the baby’s father help support you emotionally or financially?   Yes No
Where is the baby’s father?  
Is this your first baby?   Yes No
If No, do you have other kids
that live with you?		   Yes No
Describe your present circumstances:  
Are you currently in school?    Yes No
If Yes, where?  
Are you working?   Yes No
If Yes, what is your position?  
What are some of your goals for your life?  
What are some things you think are important for your baby to have in life?  
What baby items do you need or want for your baby?  
How did you hear about us?