Referring Agency Agreement
Cribs for Kids® partners and referring agencies agree to uphold the mission of Cribs for Kids® –
to provide safe sleep education and a portable Graco Pack ‘n Play to needy families. Partners
and referring agencies commit to making every effort to provide at least two follow up contacts
(home visits, recommended for trained professional only, and/or phone calls) to families who
receive cribs from the program. The first follow up contact will occur when the child is at least 3
months of age and the second follow up contact will occur when the child reaches 1 year of age.
If the referral is made when the infant is greater than 3 months of age than every attempt
should be made to complete two follow-up calls or visits by the time the infant is 1 year of age.
These follow up contacts may be part of the standard follow ups of the referring agency and will
include the completion of a brief survey to be filled out by the qualified agency staff member.
The survey will then be provided to Cribs for Kids® for program evaluation.
Cribs for Kids® partners and referring agencies will follow all of the guidelines outlined by Cribs
for Kids® (see Program Guidelines for Referring Agencies and Partners). If the guidelines
outlined by Cribs for Kids® are not met, the referring agency will be placed on probation for one
quarter. If guidelines are not met during the probationary period, the referring agency will not
be able to receive pack-n-plays from the Cribs for Kids® of the Midlands program for one
program year.
The effective dates of this agreement are October 1st, 2015 through September 30th, 2016.
I agree to be a representative from the following referring agency:
_____________________________________________________________________________
(Name of Referring Agency) - Please Print
Name: _______________________________________________________________________
Agency Address:________________________________________________________________
County________________________ State _____________
Zip Code_________________
Phone: _______________________________________________________________________
Email:________________________________________________________________________
Signature:_____________________________________________________________________
Fax to: Cribs for Kids® of the Midlands:
Fax # 803-434-4309
Rev 12/2015
Cribs for Kids® of the Midlands Fax # 803-434-4309
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