Request for Material Support

Material Needs Request Form

The LPC’s mission is to demonstrate Christ’s love to women and men facing unplanned pregnancy, or previous abortions by offering spiritual, physical and emotional care. We offer material assistance to these clients throughout their first year, and beyond. We also recognize that life is messy and sometimes you find yourself in a place where you just need help. If you are a parent who already has a baby and/or small child, and you are in need of material assistance, we are here for you too. We are able to offer you some diapers and wipes to assist with your urgent need. We can also get you connected to some other resources who can assist with other material needs, such as clothing items, formula, cribs, strollers, etc. Please fill out this form and we will get back to you.
Type a question
Date

Month Day Year
Date
Name *
Address *
City: *
Zip: *
County: *
Phone number *
Email *
example@example.com
Can we contact you for follow-up? *

Yes, you may contact me by phone. Yes, you may contact me by email. Yes, you may contact me by phone. Please use Caller ID to block Yes, you may contact me by mail.
Date of Birth *

Month Day Year
Date
Age:
Have you been here before? *

No Yes
If yes, when?
How did you hear about us?
All of the programs and services listed here are provided FREE of charge to you by The LPC.
What baby supplies or material support do you need? (please check all that apply) *

Diapers Infant Clothes Wipes Baby Toiletries Blankets Sleepers or Onesies Bottles or pacifiers Other
Please list the size diapers and/or clothes you need.
example, Diapers size 1, baby sleeper size 3 - 6 months
If applicable, are you currently pregnant?

YES NO
If YES, when is your due date?
type in your due date MM/DD/YYY
Limitations of Services

The Laurel Pregnancy Center is a non-profit Christian organization. The staff and volunteers have received informal training in peer counseling and do not, for the most part, have degrees in counseling. The counseling provided is not, therefore, intended as a substitute for professional therapy. The LPC affirms a biblical worldview. It is the framework for our care and education. We do not expect or require anyone we serve to share a biblical worldview.

The LPC services include a non-profit medical pregnancy help clinic. Our medical services are provided by licensed medical professionals. They provide general pregnancy health education and information. They are not a substitute for dedicated prenatal care.

All pregnancy help services are provided free to anyone.

I have read and understood the above and hereby authorize the staff of this clinic to render whatever services are necessary for my care.
I hereby authorize and permit the Laurel Pregnancy Center to contact me.
Signature

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Material Needs Request Form