Exit Baby Item Distribution 1/4/23 Please use this form to tell us more about you, your children and needed items Question Title * 1. Your name: Question Title * 2. Your Phone: Question Title * 3. Your email: Question Title * 4. Are you currently pregnant? Yes No Question Title * 5. If you are pregnant what is your due date? Date / Time Date Question Title * 6. If you have other children please provide their ages and if they are a boy or girl? Question Title * 7. What items are you in need of? Baby clothing Baby toiletires Diapers and wipes Stroller Car seat Diaper Bag Clothes for other children besides baby List any items needed that aren't listed above: None of the above Question Title * 8. Do you need other help? Someone to talk to Safe housing Help getting to prenatal appointments Community referals Help finding work/educational opportunities Post abortion healing Child care Other (please specify) None of the above Question Title * 9. We will send you text reminders regarding your item pick up time. Do you consent to receiving texts from us? Done