Diaper Distribution Intake Form :

South Puget Intertribal Planning Agency

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

FemaleMaleOtherPrefer not to share
Address

ADDRESS

Street Address Line 2

CITY STATE

ZIP
EMAIL
example@example.com
PHONE
What is your preferred method of contact?

PhoneEmail
Social Security Number
What is your primary language?

EnglishSpanishFrench/ CreoleChinese (Cantonese, Mandarin)VietnameseArabicTagalogGermanKoreanRussianBilingualMultilingualOtherPrefer not to share
Race: Select all that apply

Black or African AmericanAsianAmerican Indian/Alaska NativeNative Hawaiian/Pacific IslanderWhitePrefer not to shareOther
Ethnicity: Are you Hispanic, Latino/a, or Spanish Origin? (Select all that apply)

No, not of Hispanic, Latino/a, or Spanish originYes, Mexican, Mexican American, Chicano/aYes, Puerto RicanYes, CubanYes, Another Hispanic, Latino/a, or Spanish origin
DEMOGRAPHICS
Would you consider yourself a single parent?

YesNoPrefer not to answer
What is your employment status? (Select all that apply)

Full time Employment (40+hrs/wk)Partial Employment (less than 40hrs/wk)
Do you hold more than one full time job?

YesNo
Do you hold more than one part time job?

YesNo
Student enrolled in school and/or training program?

YesNo
Unemployed and seeking employment?

YesNo
Unemployed due to disability and unable to seek employment?

YesNo
Unemployed and not seeking employment due to another reason. Please explain:
About how much income does your household typically have in a year's time?

$0-$14,999$15,000-$34,000$35,000-$49,999$50,000-$74,999$75,000-$99,999$100,000 or more
Upload a copy of your pay stub or any other income.

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What is the highest level of education you have completed?

Less than 6th gradeMiddle School (6th, 7th, 8th)Some High SchoolHigh School DiplomaSome collegeAssociate Degree (AA/AS)Bachelor's Degree (BA/BS)Advanced Degree
How did you hear about us?
ELIGIBILITY
ELIGIBILITY: Is anyone in your household an enrolled tribal member of the following SPIPA Consortium Tribes?

ChehalisNisquallyShoalwater BaySkokomishSquaxin Island
Enrollment number
HOUSEHOLD INFORMATION
How many children do you have in diapers?
Child 1: Name
DOB

MonthDay Year
Date
Gender

FemaleMaleOtherPrefer not to answer
Race: Select all that apply

Black or African AmericanAmerican Indian/Alaska NativeNative Hawaiian/Pacific IslanderAsianWhitePrefer not to shareOther
Are you Hispanic, Latino/a or Spanish origin? (Select one or more)

No, not of Hispanic, Latino/a or Spanish originYes, Mexican, Mexican American, Chicano/aYes, Puerto RicanYes, CubanYes, another Hispanic, Latino/a or Spanish origin
Is this child special needs?

YesNo
Your relationship to this child
.
Diaper size
Is this child enrolled in Early Head Start or Head Start?

YesNo
Does your child in diapers attend daycare?

YesNo
If yes, do you have to provide diapers to the childcare provider for your child(ren) while they are in care?

YesNo
Child 2: Name
Date of Birth

MonthDay Year
Date
Gender:

FemaleMaleOtherPrefer not to answer
Race:

Black, African AmericanAmerican Indian/Alaska NativeNative Hawaiian/Pacific IslanderAsianWhitePrefer not to shareOther
Are you Hispanic, Latino/a or Spanish Origin? (select one or more)

No, not of Hispanic, Latino/a or Spanish OriginYes, Mexican, Mexican American, Chicano/aYes, Puerto RicanYes, CubanYes another Hispanic, Latino/a or Spanish Origin
Is this child special needs?

YesNo
Your relationship to this child?
Diaper size:
Is this child enrolled in Early Head Start or Head Start?

YesNo
Does your child in diapers attend daycare?

YesNo
If yes, do you have to provide diapers to the childcare provider for your child(ren) while they are in care?

YesNo
Child 3: Name
Date of Birth

MonthDay Year
Date
Gender

FemaleMaleotherprefer not to share
Race: Select all that apply:

Black or African AmericanAmerican Indian/Alaska NativeNative Hawaiian/ Pacific IslanderAsianWhitePrefer not to shareOther
Are you Hispanic, Latino/a or Spanish Origin? (Select one or more)

No, not of Hispanic, Latino/a or Spanish OriginYes, Mexican, Mexican American, Chicano/aYes, Puerto RicanYes, CubanYes, Another Hispanic, Latino/a or Spanish origin
Is this child special needs?

YesNo
Your relationship to this child
Diaper size
Is this child enrolled in Early Head Start or Head Start?

YesNo
Does your child in diapers attend childcare?

YesNo
If yes, do you have to provide diapers to the childcare provider for your child(ren) while they are in care?

YesNo
NEEDS ASSESSMENT
Are you receiving any of these other SPIPA services?

Childcare ServicesFood VouchersLow Income Energy Assistance Program (LIHEAP)USDA Food Distribution (commodities)WICWorkforce Development Program
Which of the following best describes your interaction with SPIPA?

This is my first time receiving diapers from SPIPAI have been receiving diapers from SPIPA for 1-6 monthsI have been receiving diapers from SPIPA for 7-12 monthsI have been receiving diapers from SPIPA for more than one yearPrefer not to share
In the past 6 months:

Has your child(ren) had a diaper rash, bladder infection, or other diaper-related health issue?Have you had to take your child(ren) to the emergency room due to a diaper-related health issue?Did your child(ren) miss childcare or school due to inadequate diaper supply?Did you miss work due to inadequate diaper supply?
In the past 6 months, did you do one or more of the following to stretch your diaper supply:

Borrow money or diapers from a damily member or friendObtain diapers from an organization in your communityStretch the diaper supply you had by changing less frequentlyKept your child diaperless
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

	1	2	3	4	5
I typically have enough diapers to change my child as often as I need to
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

Clear
DATE

MonthDay Year
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

MonthDay Year
Date
Should be Empty:

South Puget Intertribal Planning Agency

APPLICANT INFORMATION

DEMOGRAPHICS

ELIGIBILITY

HOUSEHOLD INFORMATION

NEEDS ASSESSMENT

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