Baby Book Order Form

Fill out the form below to receive a free copy of the Healthy Mothers, Healthy Babies Prenatal and Infant Care Baby Book. Baby Books are available without charge to Washington State residents only. Health and social service providers in WA are welcome to order one complimentary copy.

Any and all information you submit will be kept confidential.  It will only be used to plan and evaluate healthcare services for pregnant women in Washington State.  Your name and address will be used to mail your book and will not be shared with any individual or agency.

Mothers Information:
Your Email (If you want a confirmation )
First Name
Last Name
Street Address
City
State	WA
Zip
Year of Birth	1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020
Race/Ethnic Origin	Alaska Native Asian Black/African-American Hawaiin/API Hispanic Native American Other Race White
Current Trimester	1 2 3 Post
Family Size (A pregnant women counts as a family of TWO)	2 3 4 5 6 7 8
Family Income (before taxes) PER MONTH	$1,978 or less $2,481 or less $2,984 or less $3,487 or less $3,990 or less $4,493 or less $4,996 or less
Our books come in 6 Languages, please choose the one you want:	English Korean Russian Somali Spanish Vietnamese
Denotes a required field
Provider Information:
Provider Name
Provider Email
Provider Phone Number	(555) 555-1234
For more information, contact Debbie Nakano at debbien@withinreachwa.org