Bags for Moms Program

Having a child can be an anxious time, especially in this Covid-19 climate. The Village Hands wants to be able to help lower this anxiety, so we are offering special bags to Moms.

Please fill out the How Can We Help Form, and provide your info here. We will be in touch soon.

Bags for Moms

** Baby essentials will be given - for example diapers, wipes, baby towels and baby care toiletries

First Name

Last Name Please use your last initial if this is more comfortable

Date of Birth

Phone

Address

Address Line 2

City

Zip

Baby's gender

Female

Male

Baby's due date

Comments:

If you were referred by someone, please leave their name:

Phone

Release of Information

I authorize The Village Hands to release my information to any and all referral agencies to include, but not limited to, child assistance services, hospitals, housing agencies, and any other facilities that may offer assistance with my needs.

By checking this box, you agree to allow The Village Hands to release your information as stated above.

Signature

Date

By clicking the above button, I consent to be contacted by The Village Hands and Webit, Inc. at any email address or telephone number I provide, including, without limitation, communications sent via text message to my cell phone or communications sent using an autodialer or prerecorded message. This acknowledgement constitutes my written consent to receive such communications. I agree and consent to any applicable Terms and Conditions of Use or Privacy Policy available on this website.

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