Community Baby Shower
Event Timing: March 30, 2024
Event Address: 323 Liberty Road, Adams County Community Safe Room
Contact us at (601)807-6528 or
Email *
Date  *
Name/Age/Race *
Education Level *
Income Level *
Address/City/ State/ Zip Code *
Email *
Name & Age of invited guest *
CERTIFICATION STATEMENT This Certification form is being completed in connection with the receipt of SOUTHWEST DIAPER BANK OF THE MISS-LOU Assistance.  Program officials may verify information on this form.  I am aware that deliberate misrepresentation may subject me to prosecution under applicable State and Federal statutes.  I have been advised of my rights and obligations under the program.  I certify that the information I have provided is correct to the best of my knowledge. I release the SOUTHWEST DIAPER BANK OF THE MISS LOU, its administrating agency, its officers, employees, and volunteers from any liability resulting from the SW DIAPER BANK distribution and agree to hold them harmless against all liabilities, damages, losses, claims, causes of action and suits of law or inequity or obligation whatsoever arising out of or attributed to any actions during the implementation of the  SW DIAPER BANK OF THE MISS-LOU. 

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All information is confidential.  By completing this form in full, you are helping to make it possible for us to give you the kind of service we are sure you would like to receive.  It is our policy not to trade or share information.  
 It is our policy not to trade or share information.  Diaper Bank Member’s Signature and Date SW Diaper Bank Staff & Date below:  *
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