Diaper Distribution Intake Form :

South Puget Intertribal Planning Agency

Family and Community Resources - Diaper Distribution Intake
APPLICANT INFORMATION
NAME
How do you describe yourself?
Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
EMAIL
example@example.com
PHONE
Format: (000) 000-0000.
What is your preferred method of contact?
Social Security Number
What is your primary language?
Race: Select all that apply

Other
Ethnicity: Are you Hispanic, Latino/a, or Spanish Origin? (Select all that apply)
DEMOGRAPHICS
Would you consider yourself a single parent?
What is your employment status? (Select all that apply)
Student enrolled in school and/or training program?
Unemployed and seeking employment?
Unemployed and not seeking employment due to another reason. Please explain:
Do you have regular care for all of your children so you could go to work or school?
Average Monthly Household Income:
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What is the highest level of education you have completed?
How did you hear about us?
ELIGIBILITY
Is anyone in your household enrolled in a federally recognized Tribe?
Affiliated Tribe and Enrollment Number
LOCATION: do you live on or near the following Tribal reservations?
Upload a picture of your Tribal ID

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HOUSEHOLD INFORMATION
Number of children in the household (under 18 and reside in the household at least part time)
Number of adults in the household (over 18, reside in the household at least part time and are part of the applicant's economic unit)
Please complete the following for each child in diapers:
Child 1: Name
DOB

MonthDayYear
Date
Gender
Race: Select all that apply

Other
Are you Hispanic, Latino/a or Spanish origin? (Select one or more)
Is this child special needs?
Your relationship to this child
.
Diaper size
Is this child enrolled in Head Start or daycare?
Does your child in diapers attend daycare?
If yes, do you have to provide diapers to the childcare provider for your child(ren) while they are in care?
Child 2: Name
Date of Birth

MonthDayYear
Date
Gender:
Race:

Other
Are you Hispanic, Latino/a or Spanish Origin? (select one or more)
Is this child special needs?
Your relationship to this child?
Diaper size:
Is this child enrolled in Head Start or daycare?
Is this child enrolled in child care?
Does your child in diapers attend daycare?
If yes, do you have to provide diapers to the childcare provider for your child(ren) while they are in care?
Child 3: Name
Date of Birth

MonthDayYear
Date
Gender
Race: Select all that apply:

Other
Are you Hispanic, Latino/a or Spanish Origin? (Select one or more)
Is this child special needs?
Your relationship to this child
Diaper size
Is this child enrolled in Early Head Start or Head Start?
Is this child enrolled in Head Start or daycare?
Does your child in diapers attend childcare?
If yes, do you have to provide diapers to the childcare provider for your child(ren) while they are in care?
NEEDS ASSESSMENT
Are you receiving any of these other SPIPA services?
If not, would you like to have more info?
Which of the following best describes your interaction with SPIPA?
In the past 3 months:
In the past 3 months, did you do one or more of the following to stretch your diaper supply:
Is it currently a challenge ot get all of the diapers your child/children need?
On a scale of 1-5 (with 1 being strongly disagree and 5 being strongly agree)

Please rate your agreement with the following health statements

Rows	1	2	3	4	5
I often must reduce spending on other essential needs (food, utilities, etc.) to afford diapers
I often feel stress about having enough diapers for my child(ren)
I often feel stress about being able to provide my family with essential needs such as food, clothes, and shelter.

Certification

I realize that any false statement or misrepresentation knowingly made by me for the purpose of obtaining assistance under this program may result in my being denied assistance and/or may result in action against me which could subject me to Civil and/or Criminal penalties. I understand that by signing this application, I give up my consent to any investigation to verify or confirm the information I have given.
Applicant SIGNATURE
DATE

MonthDayYear
Date
FOR OFFICE USE ONLY DO NOT WRITE BELOW THIS LINE.

I certify that I have reviewed the proof of income documents and/or obtained letter verification of the statement made by the applicant.
DATE

MonthDayYear
Date
Should be Empty:

South Puget Intertribal Planning Agency

APPLICANT INFORMATION

DEMOGRAPHICS

ELIGIBILITY

HOUSEHOLD INFORMATION

Please complete the following for each child in diapers:

NEEDS ASSESSMENT

On a scale of 1-5 (with 1 being strongly disagree and 5 being strongly agree)