Crib Application for Families
Please fill out this application to be considered for a gift of a new portable crib, crib sheet, sleepsack and other safe sleep materials.
Date *
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First Name *
Last Name
Cell Phone *
Email *
Age *
Address *
City *
State *
Zip Code *
Is the above address your shipping address? If NO, please type in your shipping address below. *
If you were referred by one of our partner agencies for a crib, please put in their agency name and contact person name, and their cell phone
Baby's first name (if you don't have a chosen name, type unknown) *
Baby's Gender (if you don't know, type UNKNOWN) *
What is the baby's birthday or your due date? *
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DD
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Current or Planned Sleep Location (couch, chair, swing, car seat, adult bed, bouncy seat, used or new crib, bassinet, cradle) Please explain. *
Current or planned sleep position (belly, back, side, incline, other) Please explain. *
If a crib isn't available, what will your baby sleep in? *
Where did you hear about Safe Sleep for Northwest Babies Crib Program? *
Please explain your circumstances and how this gift will support you and your baby. *
Where did you previously learn about safe sleep practices? (Check all that apply) *
Required
I cannot afford to purchase a crib myself and my child does not have safe space for sleep. If this is true, type your full name below. *
Do you live in Idaho or Washington? *
I pledge to place my baby ALONE, on their BACK, in a safe CRIB in a SMOKE-FREE environment for every sleep and to tell anyone who watches my baby that this is the rule! I also affirm that I have received a minimum of 45 minutes of safe sleep education from a safe sleep educator or by attending a "Safe Sleep 101" class. Type name below. *
I have to the best of my ability attempted to secure these item(s) for myself. I understand that I must complete Safe Start's "Safe Sleep 101" class to be eligible to receive a crib. I agree not to sell any item I receive from Safe Start. I understand that acceptance of this application does NOT guarantee a crib will be available. Type your name below if you agree. *
Statutory Immunity From Liability, Safe Start a program of Northwest Infant Survival and SIDS Alliance Northwest Infant Survival and SIDS Alliance, a 501C3 non-profit corporation, is not liable for civil damages or criminal penalties resulting from the nature, age, condition, or packaging of the donated children’s items UNLESS it acts with gross negligence or intentional misconduct. I understand that by accepting items from Northwest Infant Survival and SIDS Alliance, I am assuming all risks inherent in the use of the items distributed by Northwest Infant Survival and SIDS Alliance and hereby waive, individually and as a parent and guardian of a minor child or children, all claims for civil damages resulting from the nature, age, condition, and packaging of the donated items. By signing below, I have checked over the contents of the “Safe Sleep Survival Kit” including, but not limited to, Halo SleepSack, portable crib with a bassinet, sheet, pacifier, board book, room thermometer and pamphlets. I acknowledge that all contents are in brand new working order, clean and free of odor, stains, rips or tears and that I am accepting the “Safe Sleep Survival Kit” as is. I understand that this portable crib is being provided free of charge for my family’s personal use. I agree to use it as directed, and not to re-sell these items. Type name and date below. *
Do you have reliable transportation? Information is being collected only for informational purposes. Optional to answer
Clear selection
How many people (include pregnancy) in your household? Information is being collected only for informational purposes. Optional to answer
Employment-Information is being collected only for informational purposes. Optional to answer
Clear selection
Household Income-Information is being collected only for informational purposes. Optional to answer and will not be used to determine qualification for a crib
Clear selection
Race- Check all that apply. Information is being collected only for informational purposes. Optional to answer
Hispanic Origin Information is being collected only for informational purposes. Optional to answer
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