Instructions:  The questions below are necessary for participation in the West Virginia Mothers and Babies Support Program (the “Program”).  The person completing these questions must have legal authority to bind the organization to the answers, such as the Executive Director or Board Chair/President.

All questions must be answered. We strongly encourage you to review our Question-and-Answer document before completing this Registration/Application.

Upon successful completion of this Registration/Application, your responses will be reviewed. A registration must be completed for each location you wish to participate.

While some organizations have primary offices in other states, only site locations inside West Virginia will qualify for participation in the Program, contingent upon approval. If accepted, you will be provided a contract which you will be required to sign to participate in the Program.

Services already reimbursed or funded by another government grant are not eligible for reimbursement. (Does not include NIP credits or private donations.)

If you have any questions or problems with this form, please contact Kristen Fry, Program Director at Kristen.F@wvpcc.org, (304) 421-5608, or Jenny Entsminger at Jenny.E@wvpcc.org, (304) 421-5604

2024-2025 Registration

1. Organization Details:

2. Other Government Funding Information:

3. Internal Revenue Service 501(c)(3) Status Affirmation:

4. Pro-Life Affirmations:

5. Program Compliance Affirmations:

6. Internal Documentation Affirmations:

7. Site Visit Affirmation:

Need to finish later, or want to transfer this form to your phone? Use the Save & Resume Later Button below. (Uploading the 501c3 validation proof is easy from a smart phone, just snap a pic.)

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