Program Participant Application (2021)
Rosemary’s Babies Company Confidant Care Support allows our organization to provide 24/7 financial, emergency and emotional support for teen parent families, moms and dads (13-19), in the tri-state area (Ohio, Kentucky, Indiana). This service is free of charge ($0.00).
Families are able to contact Rosemary’s Babies virtually:
Call or Text: (513) 813-TEEN (8336)
Email:
rosemarysbabies.cincy@gmail.com
Website:
www.rosemarysbabies.co
Social platforms: Facebook, Instagram, Twitter, Google, LinkedIn
* Required
Email address
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Your email
Today's Date
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MM
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DD
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First Name
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Your answer
Last name
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Your answer
Address
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Your answer
City
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Your answer
Zip Code
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Your answer
Please list your neighborhood
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Your answer
Phone Number
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Your answer
How would you prefer to be contacted
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Text
Call
Social media
Email
Required
If social media, what is your name (username) on social media? Which platform i.e. IG, FB, Google, LinkedIn, SnapChat, Twitter
Your answer
Age: List your current age (teen parent only 9-19), We will verify.
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Your answer
Sex
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Choose
Female
Male
Non-binery
Prefer not to say
Race
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Black (African American)
White (Caucasian)
American Indian/Alaskan Native
Asian
Native/Pacific Islander
Other
DO NOT WISH TO DISCLOSE
Ethnicity
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Hispanic or Latino
Non-hispanic or Latino
DO NOT WISH TO DISCLOSE
Birthday: List the birthday of the applicant (teen parent)
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Your answer
Are you:
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a teen parent, I have a baby and I am 13-19 years old
a pregnant teen, I am currently 13-19 and carrying my baby
a parent of a teen parent, I am the parent/guardian of a teen (13-19) who is pregnant, parenting or both
Other:
Background: Teen Parent: How many children do you have, sex, age. Pregnant teen: Due date, sex of baby,
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One child
Two children
Three Children
First Child Full Name
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Your answer
First Child Sex
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Choose
Female
Male
Non-binery
Prefer not to say
First Child Age
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Your answer
First Child Birthdate
*
Your answer
Second Child Full Name
Your answer
Second Child Sex
Choose
Female
Male
Non-binery
Prefer not to say
Second Child Age
Your answer
Second Child Birthdate
MM
/
DD
/
YYYY
Third Child Full Name
Your answer
Third Child Sex
Choose
Female
Male
Non-binery
Prefer not to say
Third Child Age
Your answer
Third Child Birthdate
MM
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DD
/
YYYY
Who do you live with?
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Choose
Self
Parent
Boyfriend
Fostercare
Homeless: By state definition couch hopping, displaced from family, living on street or in a shelter
Other, someone other than parent or guardian
What is your occupation?
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Student
Employed
I am not employed and currently receive cash assistance
I am a HS or college student and I receive cash assistance
I am a HS/College student and I am employed
Required
If employed, where do you work and what is your hourly salary?
Your answer
If a student what school do you attend?
Your answer
What grade are you in?
Freshman
Sophomore
Junior
Senior
Clear selection
Rosemary's Babies provides emergency resources for families during this time, during and after child-birth.
On a scale from 1-5 how do you feel emotionally during this crisis?
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Depressed I need to talk to someone
1
2
3
4
5
I am in a good space and feel healthy
Would you like to speak with someone about your health and well-being?
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Yes, text me
Yes, call me
Yes, email me
No, but I do understand I can contact Rosemary's Babies 24/7 vial all social media.
Emergency Transportation
During these times you or your baby may have medical appointments or need transportation to a family or friends. Transportation support can be rideshare, bus card/token or Uber, Lyft or other means. A household/family should not exceed more than $30 per month for transportation.
Emergency Resources
Emergency Resources: The nation is currently in a state of emergency. We are able to help in the following areas for families. A household/family should not exceed more than $50 in emergency resources per month.
If financial support is provided do you have one of the following electronic
CashApp
PayPal
Venmo
I have neither and will need a gift card
I have neither and would prefer check
I have neither and prefer items ordered for me and delivered to my house
Clear selection
Household | Utility | Other resources
Housing and resources are vital for young families in times of this nationwide emergency and throughout the year. Rosemary’s Babies will provide support for those families facing disconnection, eviction, and other similar issues based on individual circumstances.
Explain your needs for household | utility | other resources
Your answer
If you are under 18, what is your parent or guardians name, phone &/or email
Your answer
Does your parent or guardian know you have contacted Rosemary's Babies Company for support? (Responding "no" does not disqualify you for support?)
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Yes
No
Are you affiliated with Rosemary's Babies?
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I attend Seeds to Inspire (Tuesdays)
I have attended a past event
I am participant in Seeds to Inspire program
This is my first time contacting Rosemary's Babies
Who referred you to Rosemary's Babies for Confidant Support?
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Website
Agency
Online media
Google
Other:
Is there anything other than the services listed above we can help you with?
Your answer
Electronic Signature
By signing below, I certify all information is true and correct to the best of my
knowledge.
Please print your name as verfication to submit
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Your answer
Date
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MM
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DD
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YYYY
Please allow Rosemary's Babies up to 72 hours (3 days) to respond to your request. If you have an immediate need that you are unable to wait for a response, please text/call (513)813-8336
These funds for services are distributed on a case by case basis at the discretion of the agency and are not guaranteed as they are based upon availability of resources.
Rosemary's Babies Company is a teen parent and family support organization
Send me a copy of my responses.
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