Is this your first visit to Oaks of Central PA- New Mom's Corner?
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Yes
No
Client Last Name
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Client First Name
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Address
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City
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State
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Zip Code
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Phone Number
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Email
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example@example.com
What is your age?
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under 18
19-24
25-30
30-40
over 40
Are you married?
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Yes
No
Ethnicity
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White
Hispanic or Latino
Black/African American
Asian/Pacific Islander
What's the highest degree or level of education you have completed?
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Some High School
High School
Bachelor's Degree
Master's Degree
Ph.D. or higher
What is your annual household income?
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Less than $25,000
$25,000 - $50,000
$50,000 - $100,000
$100,000 - $200,000
More than $200,000
What is your current employment status?
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Employed Full-Time
Employed Part-Time
Unemployed
Student
Describe the nature of your financial hardship.
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Unemployed due to covid-19
Loss of income/revenue due to covid-19
Unexpected expenses
How many children do you have?
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None
1
2-4
More than 4
Child or Dependent under age 4 Name, Age, Birthday, and Diaper Size
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Child or Dependent under age 4 Name, Age, Birthday, and Diaper Size
Additional Children or Dependents under age 4 Name, Age, Birthday, and Diaper Size (please list all)
Are You Pregnant?
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Yes
No
Due Date *If Pregnant
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Month
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Day
Year
Date Picker Icon
Support Person First and Last Name (person you give permission to come to the center on your behalf to pick up diapers/clothing)
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How did you hear about Oaks of Central PA?
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FORMULA AND BABY EQUIPMENT RELEASE AND DISCLAIMER
Oaks of Central PA does not determine or in any way verify the recall status of any donated baby clothes, toys, equipment or supplies, ALL OF WHICH ARE PROVIDED AS IS WITH NO SEPARATE WARRANTIES, EITHER EXPRESS OR IMPLIED, AND SPECIFICALLY DISCLAIMS ANY AND ALL EXPRESS OR IMPLIED WARRANTIES INCLUDING WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. Safety issues of any nature are the responsibility of the person or persons accepting the items. I agree to disclaim, waive and release Oaks of Central PA and its agents from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, and particularly on account of any and all injuries, known and unknown, to person or to property or both, which result in any way from the use of materials provided by or obtained from Oaks of Central PA. Furthermore, Oaks of Central PA will not be held liable for any injury to me, my children, or any other adults or children, or any damage to property by the use of any such materials. I am using such materials at my own risk. I accept the responsibility for ensuring that any items borrowed by me from or donated to me by Oaks of Central PA are safe, in good repair, and are appropriate for use with my children. I likewise understand that if I choose or accept a brand or type of formula not prescribed by my doctor or WIC clinic, that Oaks of Central PA will not be held liable.
PLEASE ACCEPT
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I AGREE
By entering your name below, you are effectively providing your signature, indicating that you agree.
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Signature
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