To qualify:
you are 32+ weeks pregnant OR a parent of an infant under 12 months old
WIC eligible

Portable crib available for infant safe sleep

Please complete this form and an Allen County Public Health(ACPH) staff member will call you within 2 weeks.

If you would rather complete this form in-person, call ACPH at 419-228-4457 and ask for Cribs for Kids.

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* 1. First Name

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* 2. Last Name

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* 3. Phone Number

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* 4. E-mail address

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* 5. What is your address? (street number, street name and city)

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* 6. Are you the parent or legal guardian of a child under 12 months old OR currently 32 weeks or more pregnant?

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* 7. Please enter the child's birthdate or due date

Date

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* 8. Do you qualify for WIC and/or Medicaid?

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* 9. What is baby's race and ethnicity? Choose all that apply.

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* 10. How did you hear about the Cribs for Kids program?