Baby Steps Support Request

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Email *

Confirm email address

First Name
*

Last Name
*

Address

Mobile Phone Number

Do you prefer phone calls, text messages, or emails?

Phone Calls

Text Messages

Emails

Other:

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Who is looking for support?
*

Mothers

Father

GrandParent (at this time grandparents are only eligible if they have custody of the newborn)

Other:

What is your due date or if postpartum baby's day of birth?
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YYYY

Would you like to attend one of our Community Baby Showers?
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Yes

Does your new or pending baby have any siblings? Please provide their names and ages below and we will try to match you with a sponsor to provide a small gift for them. **Sibling gifts are limited and subject to availability.

How would you like to engage with us?

Receive a one time Pregnancy Stork Box for moms -delivered at any time during your pregnancy, up to one month prior to delivery.

Receive a one time Postpartum Stork Box for moms -delivered one month prior to delivery or up to one year after birth.

Receive a one time Father Stork Box for dads - up to one year after birth.

*The Care/Encouragement Program offers a Stork Box to anyone enrolled. Once engaged, one pack of diapers and wipes will also be sent to the baby's primary household, once per month, until the new baby is 1 year old. [A participant from the baby's family must engage at least once per month with their mentor to receive the monthly gift]

**One Mentor Program incentive gift per baby.**

Pregnancy Stork Box

Postpartum Stork Box

Father Stork Box

Care/Encouragement Program - Mother

Care/Encouragement Program - Father

Care/Encouragement Program - Kinship Care - for grandparents or foster parents with custody of baby

Other:

Tell us a little bit about yourself – your family – how your pregnancy is going/specific needs/pregnancy complications?

How can we be praying for you and encouraging you right now? Future requests can be placed here: Prayer

Waiver and Release of Liability *

I expressly acknowledge that my participation in Baby Steps Ministry mentor and donation program (the “Program”) is undertaken at my sole risk, and I agree to assume and accept all known and unknown risks from my participation in the Program. I agree to read and adhere to all safety material on all donated baby products and to inspect prior to use and acknowledge that they are received from Volunteers and are in good order. I agree to engage peacefully with any mentor appointed to me, and to cease and desist any communication deemed inappropriate by the Program immediately when asked. I understand that Pierce Point Community Church, Baby Steps Ministry volunteers, and all of their affiliates and related entities and directors, employees, officers, and 3rd party volunteers (collectively, “Covered Persons”) make no representations, warranties or guaranties with respect to the quality or hygiene of the donated products or mentorship relationships. Once I receive the donated products, I agree that Covered Persons shall not be responsible for any adverse reactions, side effects, injury, bodily harm or death that results from the donated products or any other liability arising thereof. I agree to defend, indemnify, and hold harmless all Covered Persons for any and all claims arising out of personal injury, including illness, bodily injury or death sustained or incurred by me or third parties arising out of or in connection with my participation in the Program. I further agree that Baby Steps Ministry and all Covered Persons are not liable for any costs incurred by me or third parties arising out of or in connection with my participation in the Program.

Without limiting the foregoing, I hereby irrevocably covenant and agree to refrain from, directly or indirectly, asserting any claim or demand, or commencing or instituting, or causing to be commenced or instituted, any action, lawsuit or other proceeding of any kind, against any Covered Person, based upon my participation in the Program and/or any claim or matter released hereby. Such release and waiver is to be binding upon my heirs, executors, administrators and assignees.

By checking this box I confirm I have read and fully understand this Waiver and Release of Liability Agreement.

I Understand and Agree to this Waiver Completely

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