REQUEST FOR MATERIALS FORM
Instructions for the Stork's Nest representative: In order to receive Stork's Nest materials, return completed form(s) to the
March of Dimes National Headquarters, attention Manager, Community Programs. Stork's Nest materials include *: 1 binder,
that contains the Implementation Guide/Prenatal Education Curriculum; 1 Kit (includes: 50 client bags, 50 magnets, 50
membership cards, 50 graduation certificates, 50 "Be Good to Your Baby" brochures, and 100 stickers); and 1 Birth Certificate.
Please complete one form for each Nest. Allow three-four weeks to receive your Stork's Nest kit.
Stork's Nest location, telephone, Mailing address (if different) MOD use only
fax, email: Chapter code:
Date contacted ZPB:
Date sent SN sign:
Date sent SN kit:
Is the Nest: New Re-opened Existing Date of Nest opening:
Zeta Phi Beta Chapter Name: Address, telephone, fax, e-mail:
Please place a check next to the person who should receive the Stork's Nest materials
Name of Basileus: Address/Telephone:
Stork's Nest Chairperson: Address/Telephone:
Stork's Nest is operated by: (check one)
Graduate Sorors Graduate and Collegiate Sorors Sorors and Amicae Other
Days/hours of Stork's Nest operation:
Stork's Nest is funded by: (check all that apply)
March of Dimes grant/in-kind Fund raising
Foundation/corporate grant Other: (please specify)
What is the Stork's Nest presently providing: Incentive component only
Educational component only Both
March of Dimes/Zeta Phi Beta Sorority, Inc.
Which March of Dimes chapter did you work with?
Name of your March of Dimes contact:
What is the Zeta's level of involvement with the March of Dimes:
Zetas serves on March of Dimes board or committees
Nest receives donation items
Nest receive funds from March of Dimes
Zetas participate in March of Dimes fund raising events
* Note: If you are an existing Nest, you get: 1 binder, that contains the Implementation Guide/Prenatal Education Curriculum;
1 Kit (includes: 50 client bags, 50 magnets, 50 membership cards, 50 graduation certificates, 50 "Be Good to Your Baby"
brochures, and 100 stickers); and 1 Birth Certificate.
If your Nest is new or re-opening, you get: 1 binder, that contains the Implementation Guide/Prenatal Education Curriculum.
Upon activating the Nest, you will receive the Stork's Nest kit (the same as above), and 1 Birth Certificate.
Please return this form to:
March of Dimes National Office
1275 Mamaroneck Avenue
White Plains, NY 10605
Tel: (914) 997-4571 Fax: (914) 428-9366