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Moms for Moms Partner Agency Application
Please note completion of the application form does not guarantee acceptance.
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Nonprofit Name:
Your answer
EIN #:
Your answer
Agency Address:
Your answer
Agency Website:
Your answer
Partnership contact person:
Your answer
Email Address:
Your answer
Your agency is a:
501c3
Religious Organization
Government Organization
Other:
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If needed, can you provide proof of your organization’s status
Yes
No
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Agency mission/service provided to the community:
Your answer
How will the Postpartum Recovery Kits and Newborn Baby Bundles be used by agency
On-site residential program
Emergency supplies for mothers (off-site)
Other:
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Describe the population you serve: Demographic composition (racial, ethnic, income level, age, etc…) including percentages if available:
Your answer
Geographic location by county and zip code:
Your answer
The single mothers we serve are dealing with one or all of the issues below (please check all that apply):
Job insecurity
Domestic violence
Teenage pregnancy
Homelessness
Other:
Organization’s Annual Operating Budget:
Your answer
Organization’s Staff Size:
Your answer
Why are you interested in partnering with Moms for Moms:
Your answer
What do you most hope to gain from an official partnership with Moms for Moms:
Your answer
Number of women served on a daily basis (if applicable):
Your answer
Number of women served on a monthly basis:
Your answer
Number of women served on an annual basis:
Your answer
In a best case scenario, how many newborn baby bundles would you need each year?*
Your answer
In a best case scenario, how many postpartum recovery kits would you need each year?*
Your answer
What is the maximum amount of bundles and care kits you would be able to receive at a given time (i.e. capacity to store and distribute):
Your answer
Do you work with any other partners similar to Moms for Moms:
Yes
No
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If Yes: Who?
Your answer
Our office is located in Industry City, Brooklyn. Would you be able to pickup the bags we provide you?
Yes
No
Other:
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Are you open to data sharing around the population you work with and the impact of your work to help with Moms for Moms’ reporting and fundraising efforts?
Yes
No
Partially
Please explain your response to data sharing:
Your answer
Are you open to sharing testimonials or photos (of staff/team members and/or recipients of the bundles, anonymous and face covered if needed)?
Yes
No
If no, please explain your response to testimonials:
Your answer
Are you open to public partnership recognition (i.e. mentioning Moms for Moms on your website)?
Yes
No
Partially
Please explain your response to partnership recognition:
Your answer
Are you willing to fill out an annual partnership feedback survey?
Yes
No
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*This does not guarantee that we will be able to provide this many bundles or care kits. We are doing a needs assessment to create a fundraising plan for our partnership needs.
Please note completion of the application form does not guarantee acceptance.
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