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Home Safety Program Referral Form

Country
Address Line 1 *
City *
State/Province *
Postal Code *

Indicate Safety Items/Materials Needed

Contains the following items: 12 Wide Grip Latches, 4 Grip 'n' Twist Door Knob Covers, and 30 Secure Press Plug Protectors
20 stickers per sheet
One smoke detector x # of bedroom(s) in the home
*Fits most guns
Child Safety & Injury Prevention information materials needed (please indicate requested)
This program does not supply baby gates due to liability.
Car Seat Safety Check needed:
If you indicate a car seat check is needed, staff will coordinate the check with the family.

Cribs for Kids Program for Infants (Cribette)

Families with a child under age 1 in need of a crib (Cribette - Portable Play Yard) and/or safe sleep education?  If yes, please contact CARE for a referral to the McKean County Cribs for Kids program.

Mini Crib Program

The program has a limited number of mini cribs that are appropriate for children who do not meet program guidelines for the Cribs for Kids Program.  (Over 1 year of age/ over 30lbs and under 50lbs).  Please call the office for more information.

Home Safety Program Guidelines

  1. This program is free for families with demonstrated need who reside in McKean County. Pennsylvania.
  2. The Home Safety Program was made available through grant funding; the funding necessitates that CARE for Children track item use by family/zip code.
  3. If smoke detectors and/or a carbon monoxide detector is requested, the referring professional is required to provide basic education regarding optimal safety item placement in the home and to review the family evacuation plan (which are included with the safety items).
  4. As a referring professional, you are asked to help the family determine which safety items are needed for the household, have a responsible, adult family member sign the consent to receive the items, and follow up with the family within 30-60 days to ensure that the items are in use.
  5. CARE for Children staff will follow up with the referral source, via phone, to determine if the items are in use, and with the family via a short survey to gauge the impact, if any, of the safety items; and attitudes and knowledge of home/child safety issues after 60 days.
  6. Participation in any of CARE for Children of Safe Kids Pennsylvania programs is voluntary.