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Florida Keys Healthy Start Coalition

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Need Transportation for Pre or Post Natal & Infant Doctor Appointments? Click here!

Need Assistance with Diapers, Formula, Car Seats? Click Here!

Healthy

Start

Healthy Babies

Keys to

Growing Kids

Keys to Kids Safety

Keys to Supporting Families

All Other Requests - Upper

Keys

Please complete this form if you need assistance other than diapers such as car seats, bike helmets, etc.

Adult's First and Last Name

Child #1 First and Last Name

Child #2 First and Last Name

Average Annual Income

Have you been affected by COVID-19?

Race

Single?

Yes

No

Healthy Babies Client?

Yes

No

Healthy Start Client?

Yes

No

When is this needed by?

Email

Preferred Method of Contact

E-mail

Phone Number

Phone

What other agencies are you accessing?

WIC

Food Stamps

Early Learning Coalition

Food Pantries

Other

Other

What are you requesting? (Formula, car seat, bike helmet, etc.) Why is this needed? (e.g. loss of income, loss of job, etc.)

If requesting a car seat, please fill out all fields below.

Do you own a vehicle?

Yes

No

If you own a vehicle, please provide year, make and model of vehicle. (Example: Ford, Expedition, 2016)

Are you using public transportation?

Yes

No

Can you safely travel to us to receive the car seat?

Yes

No

Child's Name, Age, Height, Weight (Please provide all)

Address

Is the child already using a car seat?

Yes

No

Referring Agency (if applicable)

Contact Information of Referring Agency

Please select the following (you may choose more than one):

I would like to sign up for the Parent Newsletter

I would like to sign up for the Community Newsletter

Neither

By requesting items, I certify that I am using these products for personal use only and not for resale. We reserve the right to refuse requests for any reason without explanation. We cannot guarantee product availability and products. We reserve the right, without liability or prior notice, to revise, discontinue, or cease to make available any or all products or to cancel any request.

Please Note: This information is strictly confidential and any personal information will not be shared.

Thanks for submitting! You should receive a a confirmation email shortly.

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