Phone

This field is for validation purposes and should be left unchanged.

Referral Group*

Please Specify*

Organisation Name*

Your Name*

First Last

Your Email*

Your Phone Number*

Is this for someone who is currently pregnant?*

Yes
No

Due Date*

PLEASE NOTE: We can only provide newborn items when the Mother is at least twenty weeks pregnant.

Please confirm the gender.*

Girl
Boy
Unknown

Do they have any other children who would need to access the baby bank?*

Yes
No

Childs Age / Gender*

If the request is for more than one child, please specify. We only ask this to enable us to make an appropriate provision of age / gender specific clothing or items, where applicable or requested.

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Items Required

Baby/Child

Mum

Maternity Clothing
Breast Pads
Maternity Pads
Nipple Cream
Nursing Bra
Breast Pump
Changing Bag

Bra Size*

Maternity Clothing Size*

Is there anything else the family are in desperate need of that hasn't been listed above?

Please be aware that we do not store cots, cot beds, car seats or prams.

Is there any further information regarding the items required?

Is there any other relevant information?

Where Did You Hear About Us?*

We provide both collection and delivery. Please select the most appropriate option below.*

Please select collection wherever possible. This is quicker and reduces pressure on our volunteers.

I will be collecting on behalf of the family.
The family will be collecting.
The family requires a delivery.

Name of Recipient*

Our address is Unit K, The Old Bakery, Golden Square, Petworth. GU28 0AP.

Our volunteers are happy to deliver within an eight mile radius of Petworth (GU28 0AP)

Name of Recipient*

Phone number of Recipient

This is optional and only used if we have a problem with the delivery.

Delivery Address*

Street Address Address Line 2 Town Postcode

By submitting this form you are agreeing to our privacy and disclosure policy as well as our assumption of risk policy.*

Please ensure you've taken the time to read and understand both policies fully. Click here to view these policies.

I have read and agree to both policies

We understand all families will have different needs regarding the items they require from the Baby Bank. We will always do our best to provide as many of the items required as possible but we won't always be able to fulfil 100% of the referral.