Program Participant Application (2022)
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
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Email *
Today's Date *
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First Name *
Last name *
Birthday: List the birthday of the applicant (teen parent) *
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Age: List your current age (teen parent only 9-19), We will verify. *
Address *
City *
Zip Code *
Please list your neighborhood *
Who do you live with? *
Phone Number *
How would you prefer to be contacted *
Required
If social media, what is your name (username) on social media? Which platform i.e. IG, FB, Google, LinkedIn, SnapChat, Twitter
Sex *
Race *
Ethnicity *
Are you: *
Background: Teen Parent: How many children do you have, sex, age.  Pregnant teen: Due date, sex of baby, *
First Child Full Name *
First Child Sex *
First Child Age *
First Child Birthdate *
Second Child Full Name
Second Child Sex
Second Child Age
Second Child Birthdate
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Third Child Full Name
Third Child Sex
Third Child Age
Third Child Birthdate
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What is your occupation? *
Required
If employed, where do you work and what is your hourly salary?
If a student what school do you attend?
What grade are you in?
Clear selection
On a scale from 1-5 how do you feel emotionally during this crisis? *
Depressed I need to talk to someone
I am in a good space and feel healthy
Would you like to speak with someone about your health and well-being? *
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
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
Is there anything other than the services listed above we can help you with?
If you are under 18, what is your parent or guardians name, phone &/or email
Does your parent or guardian know you have contacted Rosemary's  Babies Company for support?  (Responding "no" does not disqualify you for support?) *
Are you affiliated with Rosemary's Babies? *
Who referred you to Rosemary's Babies for Confidant Support? *
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 *
Date *
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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.  
A copy of your responses will be emailed to the address you provided.
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