Keep Baby Safe

Keep Baby Safe

Keep Baby Safe Application

Funding for Cribs, Mattresses and Car Seats
All form fields must be filled out completely for your application to be submitted.

You will be able to save your work should you need to exit the application before submitting. It is not advisable to fill out this application on a public computer.

This application should be submitted by a certified HSCA or Social Worker that indicates the need for a child safety containment item(s). Approval is on a case-by-case basis. All families must live in one of these three catchment areas - Northumberland, Hastings, or Prince Edward County.

Please reach out to Kelly Noakes at kelly.noakes@thechildrensfoundation.ca if you have any questions.

Section 1: Applicant Information
Hastings CountyNorthumberland CountyPrince Edward County

Parent/Guardian Information
Name*

First NameLast Name
Second parent/guardian in the household

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
How many children are in the parent/guardian's household?*

Section 2: Qualifying Criteria
What Agency is this referral from i.e. Highland Shores, BQWCHC*
Please provide an answer
Referral worker’s name*
Referral's email address*
example@example.com
Referral's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Please upload a copy of the client's Canada Child Benefit notice or other proof-of-income document for low-income requirement review:

Cancelof
When do you need the item(s) by?*
Date

Section 4. Permissions & Signature

Almost done!
YesNo
Signature*
Date signed*

MonthDayYear
Date
If you have any questions about this form, please submit an email to info@thechildrensfoundation.ca
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