The Penny Project Foundation Application

1
Mother of infant name
First Name
Last Name
2
Father of infant name
First Name
Last Name
3
Phone Number
Please enter a valid phone number.
4
Email
example@example.com
5
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Who are you applying for?
My Baby
My Grandchild
Other Relative
Friend
Other
7
What is the Infants date of birth or expectant date?
8
Marital Status
Married
Separated
Divorced
Single
9
How many incomes support this household?(Please note that dishonesty of income will result in a disqualification as a recipient.)
10
What is the annual house hold income of the family receiving the sock?Please Include ALL income (please note that any dishonesty of your income will result in disqualification.)
Less than $15,000
$50,000- $74,999
$15,000- $34,999
$75,000- $99,999
$35,000- $49,999
$100,000 or More
11
Do you receive child support?
Yes
No
12
If yes, what is the amount received each month?
13
Do you receive state assistance?If yes, please list benefits and amounts?
14
Does the baby have any known health issues?
Yes
No
15
If you responded yes to the previous question, please explain infant's health condition:
16
Does your child have health insurance coverage? If yes, please type under whom the child receives this coverage from.
17
Have you ever had miscarriage, stillbirth or lost an infant to SIDS or another health condition?
Miscarriage
Stillbirth
Lost an Infant to SIDS
Lost an Infant due to other health conditions
18
How many children are currently in the household?
0-1
2
3
4
5
Other
19
If you answered other to the previous question, please tell us how many children are in the household.
20
Please tell us why your family is in need of an Owlet Smart Sock, please be as detailed as possible? Please understand that although we would like to assist every family with this amazing device we do not have the capabilities to do so.
21
How did you hear about the Penny Project?
Facebook
Instagram
News Article
Magazine
Friend/Relative
Other
22
If other please explain.
23
Terms and Conditions:

By submitting this application you are providing honest and accurate information. If you become an Owlet Smart Sock recipient through the Penny Project Foundation you are agreeing to let the Penny Project share your story and agree to send us a photo of your baby wearing the Owlet that we can use on our social media, website and for other media purposes such as news stories and promotional videos. Last names and addresses will not be disclosed.

By receiving an Owlet from the Penny Project you are agreeing to the terms that you will not sell the product at any time. You will take care of the product so that it remains in like-new or gently-used condition, and WILL RETURN the sock to the Penny Project Foundation once the child has reached 12 months of age. Doing so will allow another family to benefit from the use of this device.

The Penny project and Owlet ARE NOT responsible for diagnosing infant illnesses nor does the Owlet prevent SIDS from occurring. This device is not a life saving monitoring device and we still urge safe sleep practices.

References or proof of information will be required for approval.
24
I have read the terms and conditions and agree to them.
I agree
25
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