1.Are you a Holmes County Resident? You must be a resident to qualify for this program.

Yes

No

2.Parent/Guardian Name:

3.Child's Birthday or Due Date: (Child must be under the age of one to qualify)

4.Phone Number:

5.Address:

6.I understand I will need to arrange pick of pack 'n play at the Health District with a Health Educator.
*If you answer NO you will not be able to receive this item.

Yes

No