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, (304) 421-5608, or Jenny Entsminger at, (304) 421-5604

Paper Form Option

If you would prefer to mail in a paper form it can be found here. Please note additional processing time will apply.