Temporary Diaper Assistance
If you need diapers and have been effected by the COVID-19 Pandemic, please fill out the following information. Once submitted, a staff member from the Austin Diaper Bank will contact you to setup an appointment.
First Name/Nombre de Pila *
Last Name/Apellido *
Date of Birth/Fecha de nacimiento *
MM
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DD
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YYYY
Phone Number/Número de teléfono *
Email Address/Dirección de correo electrónico *
Street Address/Dirección de la calle *
City/Ciudad *
State/Estado *
Zip code/Código postal *
County of Residence/Condado *
What is your preferred method of communication?/¿cuál es su método preferido de comunicación *
Ethnicity *
Have you lost income due to COVID-19/¿ha perdido ingresos debido a COVID-19 *
Are you enrolled in or receive assistance from any of the following agencies? *
Required
Household Information/Información del hogar
To receive diapers you must fill out the household information completely.
How Many Adults live in your household?/Cuántos adultos viven en su casa *
How Many Children under 18 live in your household?/¿Cuántos niños menores de 18 años viven en su casa? *
How many Children in your household wear diapers? /Cuántos niños usan pañales en su casa *
Date of Birth for Child Wearing Diapers/Fecha de nacimiento del niño *
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DD
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YYYY
Date of Birth for Child Wearing Diapers (2)/Fecha de nacimiento del niño
MM
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DD
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YYYY
Date of Birth for Child Wearing Diapers (3)/Fecha de nacimiento del niño
MM
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DD
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YYYY
Income for Household (Yearly)/ingresos anuales para el hogar *
Do you or does anyone in your family receive any of the following benefits? Check all that apply. / ¿Usted o alguien de su familia recibe alguno de los siguientes beneficios? Marque todo lo que corresponda. *
Required
Check off the assistance you are seeking. / Marque la asistencia que está buscando *
Required
Thank you for completing this form. We will reach out shortly by phone or email to setup an appointment. / Gracias por completar este formulario. Nos pondremos en contacto en breve por teléfono o correo electrónico para concertar una cita.
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This form was created inside of Austin Diaper Bank.