APPLY

Do You Live In Collier or Southern Lee County? Do You Live In Collier or Southern Lee County? *YESNO

Parent/Guardian Name(s)

Mailing Address

Phone

Email Address

Total People In Household

How did you hear about us?

Is one parent/guardian in your home working? Is one parent/guardian in your home working? *YESNO

Any federal/state cash assistance (not WIC)? Any federal/state cash assistance (not WIC)? *YESNO

Do you meet the financial guidelines for WIC?* Do you meet the financial guidelines for WIC?* *YESNO

Monthly Household Income

1st Employer's Name

1st Employer's Number

1st Employer's Address

2nd Employer's Name

2nd Employer's Number

2nd Employer's Address

Child's Name

Child's Gender Child's Gender *MALEFEMALE

Is your child under the age of three? Is your child under the age of three? *YESNO

Child's Weight

Child's Diaper Size Child's Diaper Size *123456

Additional Child's Name

Child's Gender Child's GenderMALEFEMALE

Is your child under the age of three? Is your child under the age of three?YESNO

Child's Weight

Child's Diaper Size Child's Diaper Size123456

Additional Child's Name

Child's Gender Child's GenderMALEFEMALE

Is your child under the age of three? Is your child under the age of three?YESNO

Child's Weight

Child's Diaper Size Child's Diaper Size123456

Do You Receive Food Stamps? Do You Receive Food Stamps? *YESNO

Do You Receive TANF? Do You Receive TANF? *YESNO

Do You Receive WIC? Do You Receive WIC? *YESNO

Do You Receive Federal or State Cash Assistance? Do You Receive Federal or State Cash Assistance? *YESNO

Sign Here ***Each of these criteria will be verified before acceptance into the program.*** I, the undersigned, affirm that all information stated on this Registration Form is true, complete, and correct. I agree to promptly notify Baby Basics of Collier County, Inc., if any such information changes at any time. I agree that Baby Basics of Collier County, Inc., may verify the accuracy of such information by contacting any party with, or believed to have knowledge of such information, and hereby give my permission to Baby Basics of Collier County, Inc. and any of its volunteers to do so. I acknowledge that this Registration Form is merely an application to participate in Baby Basics Program and that I have no right to participate in the Program or to receive any goods or services from Baby Basics of Collier County, Inc. I also acknowledge that in the event that I am allowed to participate in the Program, Baby Basics of Collier County, Inc., shall be entitled to terminate my participation therein at any time with without notice in Baby Basics of Collier County, Inc.’s sole discretion. All information given here will be kept confidential by the Board of Baby Basics of Collier County, Inc. The parents/guardians agree to inform Baby Basics, Inc. if they are unable to attend the bi-monthly distributions. Failure to notify Baby Basics, Inc. two distributions in a row (one month) will result in removal from the program.

Name

Phone Number

Email Address

Message