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 3 catchment areas - Northumberland, Hastings, or Prince Edward County.

Please reach out to Donna Wood at donna.wood@thechildrensfoundation.ca if you have any questions.

Section 1: Applicant Information
What county does the parent/parent to be live in?*

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.
Email
example@example.com
How many children are in the parent/guardian's household?

Section 2: Qualifying Criteria
What Agency has referred you? 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.
When do you need the item(s) by?*
Date

Section 4. Permissions & Signature

Almost done!
I give The Children's Foundation permission to contact me for testimonials and impact stories.*

YesNo
Signature*

Clear
Date signed*

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