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0-36 Months Materials Assistance Form

I am a:(Required)
Have you registered with Care Net of Central Texas before?
Event City(Required)
We host this event in various cities. Select all you’d like to be notified about! (You don’t have to live there)
Today's Date(Required)
Date of birth of your youngest child?(Required)
Was your youngest chld's birth weight less than 5 lbs. 8 oz.?(Required)
Was your youngest child born preterm (before 37 weeks)?(Required)
List each child’s date of birth and sex on one line.
Are you a U.S. citizen or eligible for Medicaid?(Required)
Do you have access to a device for virtual meetings (Zoom)?

If you attend one of the two amazing pregnancy/parenting classes we send you, you’ll be qualified to come and pick up your items!
Your Date of birth(Required)
What city, or general area?
Marital Status(Required)
Highest education completed
For example: Size 3 diapers, 6-9 mo boy clothes, Infamil Gentlease
Among the many services we can provide you, some can help you with your spiritual health. For example, if you find comfort in prayer, someone here can pray with you, if you’d like. We offer spiritual services because they’re a part of our faith background. However, we will not offer to provide you spiritual services if you don’t want us to. All of the other services we provide are still here for you, even if you decide not to receive spiritual help. If you are open to receiving spiritual services, I will introduce you to another counselor here who will provide these services to you. And, if you prefer not to receive any services – spiritual or otherwise – from us, we will help you find another provider of your choice. Please check your preference below(Required)
How did you hear about this event?

Live bravely. Strength becomes you.