Diaper Request Form

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Diaper Request Form

The criteria for a diaper request are as follows:

Must be enrolled in Maya
Must be 0-12 months postpartum
Must have attended at least one class this month
The diaper request limit is 50 diapers per child, per month
We carry preemie to size 5 only

Email *

Name (By filling out this form I give permission to share all information on the form with the WPA Diaper Bank.) *

Phone Number *

Highest Level of Education *

Middle School

Some High School

High school (Diploma)

Some College

Associate's Degree

Bachelor's Degree

Advanced Degree

Prefer not to share

Employment Status *

Full Time (40+ hours/week)

Partial Employment (<40 hours/week)

Student Enrolled in school/training program

Unemployed/Seeking employment

Unemployed/Disability/ Unable to seek employment

Unemployed/Not seeking employment for another reason

Prefer not to share

Other:

Childcare Enrollment Status *

Yes

Prefer not to share

Are you a veteran? *

Yes

I do not wish to answer

Income Level *

WIC

SNAP

TANF

None

Number of children in the home *

Number of children receiving diapers *

Age of Baby #1 *

Age of Baby #2

Diaper Size #1 *

Diaper Size #2

Which class did you take this month? *

Requested Date & Time

Please use the calendar below to choose which date you would prefer to pick up your items. After you have submitted your request, we will contact you to confirm availability. DO NOT SHOW UP UNTIL WE HAVE CONFIRMED WITH YOU. WE MAY NOT BE THERE.

YYYY

A copy of your responses will be emailed to the address you provided.

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