Children's Diaper Bank CLIENT APPLICATION******NEW DIAPER EVENT HOURS 12 pm- 4 pm starting July 3, 2017*******
Please make sure all sections are correctly filled out before submitting. Pregnant women within two weeks of due date up to three years of age and are Virginia residents may be eligible for our program. Children graduate our program on their third birthday. Client applicant or authorized pickup person must bring picture ID to verify this application and to receive client card to the next available monthly diaper event that is convenient for you. Please go to our website for the schedule of monthly events: http://www.childrensdiaperbank.org
Please be prepared with your picture ID and time to fill out any incomplete sections or updates needed for your client application on file. All ID's will be verified to ensure safety of our volunteers and clients. Thank you for your understanding and patience.
1) All incomplete forms are flagged and denied access to program until updated. Refusal to provide information will result in immediate dismissal from our program.This applies to online applications as well.
2) Picture ID names NOT matching adult client/ authorized pick up person will result in immediate dismissal from our program.
Email address
Do you have a child under 3 years old?
I understand my eligible child(ren) will receive one bundle of 25 diapers in their current diaper size at monthly events.
I understand Children's Diaper Bank will not deliver or mail diapers. It is my responsibility to attend or have my authorized pick up person attend a monthly diaper event in Gloucester, VA 23061 to receive diapers.
Client First Name:
Your answer
Client Last Name:
Your answer
Street Address:
Your answer
City:
Your answer
State:
Your answer
Zip Code:
Your answer
Valid Phone Number:
Your answer
Adult Client Date of Birth:
MM
/
DD
/
YYYY
Gender:
Race:
Your answer
Child(ren) Lives With:
Family Demographic Information
How many adults live daily in the household including client?
Your answer
How many children newborn-3 yrs old live daily in the household?
Your answer
How many children 4-17 yrs old live daily in the household?
Your answer
Employment status of client applicant?
Does anyone in the household receive any of the following? (Check all that apply)
Required
Child(ren) in Daycare?
Client applicant have health insurance?
Child(ren) have health insurance?
If yes, what type of insurance?
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms