Baby Depot Request Form

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*

Cancelof
Date of Request

MonthDayYear
Date
Name

First NameLast Name
County of Residence*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence
Phone Number
Please enter a valid phone number.
Your Age
Race
Are you an RMOMS participant?*

YesNo
If you are an RMOMS participant, which facility do you receive care at?
When are you expecting?

MonthDayYear
Date
Is this your first time making a request at the Baby Depot?*

YesNo
How old is your baby?*

0-3 months4-6 months7-9 months9-12 monthsN/A
Are you in need of pads, tampons, or panty liners?

PadsTamponsPanty LinersNone
What size diapers do you need?

NewbornSize 1Size 2Size 3Size 4Size 5Size 6None
Do you need baby wipes?

YesNo
Do you need baby food?

YesNo
Which baby formula do you need?

Enfamil Infant Formula, Milk-based Baby FormulaEnfamil Gentlease Baby FormulaEnfamil Added Rice Infant FormulaSimilac Total Comfort Baby FormulaSimilac Sensitive Powder Baby FormulaNone
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