Application for Emergency Assistance

Healthy Start of Southwest Florida

Application for Emergency Assistance

Parent/Caretaker Name(Required)

First Middle Last

Parent/Caretaker Address(Required)

Street Address City State ZIP Code

Do you have transportation to pick up the items needed?(Required)

Yes

Any Special Instructions

Phone Number

Mobile Phone Number

Baby’s Name

Date of Birth or Estimated Date of Delivery (if pregnant)

Gender

Number of Children under 3 years in the Household

Assistance Request

Diapers

Baby Formula

Pack N Play- For sleeping

Other

Other Assistance Needed:

Do you wish to be contacted for additional Healthy Start services?By supplying your phone number and signature, you are giving the Healthy Start Coalition of Southwest Florida consent to contact you by phone and leave a message as needed. A representative from Healthy Start will contact you regarding your request.

Yes

Efforts will be made to meet your need within 24-48 hours of receiving your application (weekends/holidays not included). Emergency Assistance funds are limited. Incomplete applications will not be approved.

I Swear That All Statements On The Emergency Assistance Form Are Accurate And True.*(Required)

Yes

Electronic Signature(Required)

I agree that the “Signature” will be an electronic representation of my signature for purposes of this Application - just the same as pen and paper.(Required)

Yes

Essential Baby Supply Locations: Collier & Lee County

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FORT MYERS
1921 Jefferson Ave Fort Myers, FL 33901

Main: (239) 425-6920
Customer Service: (800) 883-1959
Fax: (239) 425-6921

HEALTHY START INFORMATION

Healthy Start Coalition of SWFL is a 501c3 not-for-profit organization with a mission to reduce infant deaths and premature births as well as improving health & developmental outcomes for young children in Collier, Hendry, Glades and Lee County. A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL-FREE (800-435-7352) WITHIN THE STATE. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE.

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FORT MYERS
1921 Jefferson Ave Fort Myers, FL 33901

Main: (239) 425-6920
Customer Service: (800) 883-1959
Fax: (239) 425-6921