Car Seat/ Pack n Play| Mom Starts Here

Car Seat/ Pack n Play Request

Requests are checked each Monday. We will contact you with questions and next steps.

Requests are approved based on your level of need and member engagement.

Pregnant? Do not fill out this form. Please click here: PREGNANCY CLUB

Requests for Car Seats or Pack n Plays will only be approved for members who have attended an event in the past 6 months.

First name

Last name

Member Number

Phone

Select an Address

Which items are you requesting? (select all that apply) Required

Car Seat

Pack n Play

Car Seat and Pack n Play

Is this for a child you are currently pregnant with? Required

Yes

What is your due date?

Please list the name, gender, and age of the children you are requesting items for:

Do you receive SNAP? If so, how much?

Pack n Play Requests only: What is your child currently sleeping in?

What is the household size on your SNAP case?

Car Seat Requests only: If you currently have a car seat, what is your reason for requesting a new one?

I don't have a car seat

My child is over the weight limit

My child is too long for the car seat