Regional request form
Thanks for visiting St Kilda Mums Rural and Regional Service.
To access our service, all social workers and Maternal and Child Health nurses must be registered with St Kilda Mums.
If you are not yet registered, please register as a regional social worker here prior to completing this form.
Please complete one form for each family you are requesting for, unless you are placing an order for bulk stock. In this instance, please add "bulk stock" in the "mother's or primary carers name" field.
For helpful hints on how to complete this form please click here.
For further assistance or for emergency requests, please contact the Regional Service Coordinator via email at email@example.com
We look forward to receiving your request soon - thank you for supporting families in need.
Currently we are experiencing great demand for our service so we are asking that you explore all avenues for funding and brokerage for cots and car seats before accessing our service. This includes any DHHS, NEP or your own agency brokerage.