Baby Depot Request Form
To receive items from the Baby Depot, one must provide proof of income (enrollment or eligibility for Medicaid) or proof of participation in the Rural Maternity and Obstetrics Management Strategies (RMOMS) program. Please upload proof below. *If proof cannot be provided, please stop here and refer an eligible mother to the Baby Depot. Thank you.
Proof of Eligiblity
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Date of Request
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of Residence
Phone Number
Please enter a valid phone number.
Age
Race
Are you in need of pads, tampons, or panty liners?
Pads
Tampons
Panty Liners
None
What size diapers do you need?
Newborn
Size 1
Size 2
Size 3
Size 4
Size 5
Size 6
None
Other
Do you need baby wipes?
Yes
No
Do you need baby food?
Yes
No
Which baby formula do you need?
Enfamil Infant Formula, Milk-based Baby Formula
Enfamil Gentlease Baby Formula
Enfamil Added Rice Infant Formula
Similac Sensitive Powder Baby Formula
Similiac Advance Powder Baby Formula with Iron, DHA, Lutein
None
Other
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