Diaper Distribution Monthly Order Form :

South Puget Intertribal Planning Agency: Family and Community Resources - Diaper Distribution

Monthly Order Form
Thank you for Diapers through the Diaper Distribution on Reservations Pilot Project.

If this is your first time applying for diaper assistance, please fill out the initial intake form

Please fill out this form and submit prior to the 15th of each month, so we may determine an appropriate amount of diapering needs for your family.
Month for order: (If you place an order this month, it will be for the following month.) *
APPLICANT INFORMATION:
Name
Relationship to Child(ren)
Tribe
Enrollment #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE*
EMAIL*
example@example.com
How do you prefer to be contacted?*

Phoneemail
Diaper Distribution is initially disposable diapers. Are you interested in cloth diapering?

YesNo
NOTE: SPIPA is only authorized to deliver to Tribal Daycare Facilities. If Daycare is with a private provider, arrangements must be made to pick up on specific days by Tribal location.
How will you receive these diapers?

Pick upTribal Daycare Delivery
Pick up: at which tribe are you located?

ChehalisNisquallyShoalwater BaySkokomishSquaxin IslandPt Gamble
DIAPER DELIVERY LOCATION

SPIPA is only authorized to deliver to Tribal Daycare Facilities. If Daycare is with a private provider, arrangements must be made to pick up on specific days by Tribal location.
Name of Tribal Daycare Facility
Tribal Daycare Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tribal Daycare Phone Number
Please enter a valid phone number.

CHILD INFORMATION: Please include name, age, diaper brand, and size. Due to incomplete forms, please add a 0 or an x in the additional child name column if you are requesting diapers for less than 4 children. *

	Child Name	Age	Brand	Size	If Pull-Up: Boy/Girl
Child 1
Child 2
Child 3
Child 4

COMMENTS: Let us know what you think!
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

South Puget Intertribal Planning Agency: Family and Community Resources - Diaper Distribution

APPLICANT INFORMATION:

DIAPER DELIVERY LOCATION