Diaper Client Application Form - Applicacion de Pañales
Once you have completed form please post your needs on our Facebook group page Earthbound Angels and someone will set an appointment to pick up. These are emergency supplies so you will receive 20 diapers up to size 5 and 15 if it's size 6 or pullups. You may request diapers twice a month.
Cuando a completado esta forma por favor publique sus necesidades en el grupo de Earthbound Angels en la pagina de Facebook y alguien le ara una cita para recojerlos. El proposito es de los pañales son de emergencia y recivira 20 pañales hasta talla 5, y 15 en tallas 6 o de pull-ups. Solo puede solicitar dos veces en un mes.
Date of Application - Fecha de Applicacion *
Date in which you first made known you needed diapers - Fecha de necesidad
MM
/
DD
/
YYYY
Name of person completing application - Persona completando la appllicacion *
Your answer
Relationship to child - Relacion al niño/niña *
I understand that the Earthbound Angels Inc. Diaper bank provides donated diapers/ wipes and cannot accomodate specific requests for styles or brands. As available, baby wipes may also be distributed. We cannot make any guarentees of availability. *
Entiendo que Earthbound Angels Inc. proporciona pañales y toallitas para bebe donados y no puede accomodar solicitudes specificas de stylos y marcas. No podemos garantizar que los productos sean disponibles.
Required
I understand that each family is asked to sign a product liability waiver as all diapers / wipes are donations provided to the Earthbound Angels Inc. Diaper Bank solely for the purpose of the Diaper Bank distribution to families in need of diapers and the Diaper Bank does not take on any responsibility or liability whatsoever for products it is distributing. *
Entiendo que cada familia se les pide que firme una exención de responsabilidad del producto para todo pañales y toallitas para bebe como los productos son donaciones que proporciona Earthbound Angels Inc. El proposito de los pañales son para distribuir a las familias con necesidad y no se toma responsabilidad por los products que se distribuyen.
Required
I understand that the diapers I am receiving are for the sole purpose of my child in need and not to be sold or distributed to other people. *
Entiendo que los pañales y toallitas para bebe son para el proposito de necesidad y no seran vendidos y distribuidos a otras personas.
Required
How many people are in your household? *
Cuantas personas en su hogar?
Your answer
How many children under the age of 5? *
Cuantos niño(a)s menor de 5 años?
Your answer
How many children over 5 *
Cuantos niño(a)s mayor de 5 años?
Your answer
What is the annual income for your house hold (Note: income is for information only and will not disqualify you) *
Cuanto gana anualmente? (Sus ingresos anuales son por propositos de información y no lo descalifica.)
Does the child attend childcare? *
Atiende su niño(a) a una guarderia?
Required
Does the childcare require a supply of diapers? *
Requiere la guarderia un suministro de pañales?
Required
Parent/Guardian has health insurance? Padre/Madre/Guardian tiene aseguranza de salud? *
If yes, what type of insurance - Que tipo de aseguranza?
Your answer
Current DHS involvement? *
Recibe beneficios por el Departamento de Salud?
Required
If yes (please select all that apply) *
Si recibe beneficios, por favor indico todos los que recibe.
Required
For your children in diapers, do you ever feel that you have enough diapers to change them as often as you would like?
Usted siente que mantiene suficiente pañales?
If yes: What do you do when you do not have enough diapers (select as many as apply)
Que hace cuando no tiene suficiente pañales?
Please tell us how this supply of diapers is MOST impacting for you today
Diganos como le ayuda el sumministro de pañales hoy.
Child's Name *
Nombre de niño(a)
Your answer
Child's address *
Direccion
Your answer
Date of birth *
Fecha de Nacimiento
MM
/
DD
/
YYYY
Parent/guardian contact name and phone number *
Nombre de Padre/Madre/Guardian y Numero de Contacto
Your answer
Contact email
Correo Electronico
Your answer
Race of child: *
Raza de niño(a)
Child lives with (select all that apply) *
Niño(a) vive:
Required
Diaper Size *
Talla de pañales
Your answer
Pull-up size
Talla de Pull-ups
Your answer
Gender *
Do you prefer diapers or pull-ups
Preferie pañales o pull-ups?
*Do you need baby wipes - Necesita toallitas para bebe?
* If available - Si hay disponible
Once you have completed form please post your needs on our Facebook group page Earthbound Angels. Cuando a completado esta forma por favor publique sus necesidades en el grupo de Earthbound Angels en la pagina de Facebook.
You may message us on our Facebook group page Earthbound Angels Inc. and someone will set an appointment to pick up; we do not deliver. These are emergency supplies so you will receive 20 diapers up to size 5 and 15 if it's size 6 or pull-ups. You may request diapers twice a month. El proposito es de los pañales es de emergencia y recivira 20 pañales hasta talla 5, y 15 en tallas 6 o de pull-ups. Solo puede solicitar dos veces en un mes.
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