JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Crib Application for Families
Please fill out this application to be considered for a gift of a new portable crib, crib sheet, sleepsack and other safe sleep materials. *Completion of "Safe Sleep 101" or direct education from a Safe Start Safe Sleep Educator is required to receive a crib. We DO NOT ship cribs. You must be able to pick up a crib from one of our crib partners. Register for "Safe Sleep 101" at
www.safestartnw.org
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
City you reside in
*
Your answer
Do you live in Idaho, Montana or Washington? Please note that our grant for portable cribs are only available for those living in ID, WA and western MT.
*
Idaho
Washington
Montana
Date
*
MM
/
DD
/
YYYY
First Name
*
Your answer
Last Name
Your answer
Cell Phone
*
Your answer
Your Age
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
You MUST be able to pick up your crib from one of our crib partners or our office in Coeur d'Alene. Are you able to do this?
*
Your answer
If you were referred by one of our partner agencies for a crib, please put in their FULL agency name and contact person name, and email address or cell phone
*
Your answer
I have completed Safe Sleep 101
*
I am registered and will complete class soon.
Yes, I have already taken the class.
No, I will register soon.
www.safestartnw.org
to register
I have been provided safe sleep education from Safe Start or a Safe Start partner agency listed in previous question
I understand that I must keep my camera on and engage in chat during "Safe Sleep 101"
*
Yes, I will keep my camera on and engage in chat during class
I didn't take class. I was directly helped by a Safe Sleep Educator
What is the baby's birthday or your due date?
*
MM
/
DD
/
YYYY
What sleep space to you currently have for your baby? Examples may be a couch, chair, swing, car seat, adult bed, bouncy seat, used or new crib, bassinet, cradle, pack and play, ect.
Please explain.
*
Your answer
Current or planned sleep position for baby (belly, back, side, incline, other)
Please explain.
*
Your answer
If a crib from Safe Start isn't available, what will your baby sleep in?
*
Your answer
Where did you hear about this program?
*
Your answer
Please explain your living, financial and other circumstances and how this gift will support you and your baby.
Please be specific.
*
Your answer
Where did you previously learn about safe sleep practices? (Check all that apply)
*
Hospital
OBGYN Office or my doctor
WIC
Family member, relative, friend
My baby's doctor
Internet Site
I have never learned about safe infant sleep
My home visitor (Early Head Start, Nurse Family Partnership, First Steps, etc)
Required
I cannot afford to purchase a crib myself and my child does not have safe space for sleep. If this is true, type your full name below.
*
Your answer
I pledge to place my baby ALONE, on their BACK, in a safe CRIB in a SMOKE-FREE environment for every sleep and to tell anyone who watches my baby that this is the rule! I also affirm that I have received a minimum of 45 minutes of safe sleep education from a safe sleep educator or by attending a "Safe Sleep 101" class. Type name below.
*
Your answer
I have to the best of my ability attempted to secure these item(s) for myself. I understand that I must complete Safe Start's "Safe Sleep 101" class to be eligible to receive a crib along with being able to pick up a crib from a Safe Start crib partner. I agree not to sell any item I receive from Safe Start. I understand that acceptance of this application does NOT guarantee a crib will be available. Type your name below if you agree.
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Inland Northwest SIDS Foundation.
Report Abuse
Forms
