Maternity Assistance Form | BTDS of America

Maternity Leave Assistance Program Application

Our non-profit is committed to practically helping moms in our community.

Birth Tissue Donor Services of America, Inc. (BTDSA) Maternity Assistance Program (MAP) provides financial, product and/or referral services for mothers who are struggling financially, who are not receiving paid medical leave, and who need assistance as solely determined by BTDSA. The money, groceries, baby products, breast pump accessories and/or other services are a gift, and repayment is not expected, nor required (the “Donation”). To apply, complete the form below.

Available Services and Assistance:

Financial Support Program
- Providing support for bills, baby essentials, groceries, car repairs, etc., during unpaid maternity leave
Prenatal Care Support
- Prenatal vitamins, birth class sponsorship, breast pump accessories
Referrals for other assistance

Please complete the following:

First and Last Name

Phone & Email

Home Address

Date of Birth

Date of Delivery

State how many people live in your home and ages:

Name and total annual Income of persons living in your home:

Name

DOB

Annual Income

Name

DOB

Annual Income

Your Employer Name, Address and Telephone Number

Do you receive employer sponsored, private and/or government assistance including but not limited to short and/or long-term disability payments, FMLA, Paid Time Off (PTO) social security, food stamps, WIC or SNAP, etc? If yes, please state ALL the benefits received and the monthly payment.

Date of Employment

Income during 2024

Last Position

Income 2025

Do you agree to allow BTDSA to contact your current employer to determine the above information and your maternity and short and/or long-term disability, FMLA and PTO, benefits?

Do you agree to allow BTDSA to contact your current employer to determine the above information and your maternity and short and/or long-term disability, FMLA and PTO benefits?

Note: BTDSA will not provide assistance if we cannot verify your employment related benefits. Do you waive your privacy and HIPAA rights and other privacy protections such that BTDS representatives may speak with your employer and your employer may verify the information contained herein? Required

Yes

Signature

Do you hold harmless BTDSA and your Employer harmless from giving and/or receiving any and all information regarding your maternity leave, information contained herein and request for benefits? Required

Yes

Signature

State your needs and what led you to request assistance. Understanding your needs allows BTDSA to better assist you.

Thanks for submitting!

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Maternity Leave Assistance Program Application

Our non-profit is committed to practically helping moms in our community.

Maternity Leave Assistance Program Application

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Our non-profit is committed to practically helping moms in our community.