KNDC/KCCC LLEGO DIAPER BANK REGISTRATION
Please answer all questions truthfully and to the best of your knowledge.—Incomplete forms may not be processed.
Only children up to 42 MONTHS (3.5 years old) are eligible to receive diapers. At its discretion and upon request, K.N.D.C may use the information requested for statistical purposes and may share the provided information with 914Cares, and other affiliated non-profit partners.
Email *
Registrant First & Last Name *
Email Address
Phone Number (Best Contact)
Address, City, State, Zip
Child First & Last Name *
Child D.O.B *
Diaper/Pullup Size *
Child First & Last Name
Child D.O.B
Diaper/Pullup Size
Do you find times of the month where providing diapers is challenging? *
Required
Are you current in need of permanent housing? *
Required
Can you use assistance with weekly groceries? *
Required
Assistance with diapers monthly can help me.... *
Required
Other thoughts or comments
Registrant First & Last Name *
Email Address
Phone Number (Best Contact)
Address, City, State, Zip
Child First & Last Name *
Child D.O.B *
Diaper/Pullup Size *
Child First & Last Name
Child D.O.B
Diaper/Pullup Size
Do you find times of the month where providing diapers is challenging? *
Required
Are you current in need of permanent housing? *
Required
Can you use assistance with weekly groceries? *
Required
Assistance with diapers monthly can help me.... *
Required
Other thoughts or comments
Submit
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