Healing Hurts Diaper Bank Item Request Form

IMPORTANT

PLEASE READ COMPLETELY BEFORE FILLING OUT THIS FORM

In order for you to get the essential items for your baby, the items must be picked up in person Monday through Friday between 10:00am and 2:00pm. If you are unable to pick up the items, please confirm the name and relationship of the individual with our office prior to pickup.

We are not able to guarantee a specific brand of diapers, toiletries, or wipes. However, please let us know if your child has an allergy or sensitivity to any baby products.We will offer options for clothing according to what is on hand at the time of pick up. You can indicate your baby's size and gender, and we will pull these items from the Healing Hurts Ministries Diaper Bank area on your behalf.

We will not be able to exchange any items received once they leave the Healing Hurts Ministries Diaper Bank. Please complete the form below and follow the instructions at the bottom of the form. If you are picking up for more than 1 child, please complete one form for each child.

To receive more items you are able to participate in our Art of Parenting and Earn While You Learn programs. If you are interested in either of these parenting programs, please indicate this information below.

Name*

First NameLast Name

Date of Birth*

Date

Ethnicity*

Phone Number*

Area CodePhone Number

Email*

example@example.com

What county do you live in?*

BerkeleyCharlestonDorchesterOther

Family Structure*

What is your baby's gender?*

What is your baby's age?*

I am in need of:*

DiapersWipesInfant/Toddler clothingAll of the above

What is your baby's diaper size*

What is your baby's clothing size?*

Monthly Income range per year*

Have you received items from the Healing Hurts Ministries Diaper Bank in the past?*

YesNo

Please indicate how many times you have picked up this year: (The maximum times for pick up is 4 per year. The item selected below will be checked in our system by our staff before pickup is completed.)*

This is my first timeThis is my second timeThis is my third timeThis is my fourth time

I would like to be contacted by phone or email to receive more information about the Art of Parenting program:*

YesNo

I would like to be contacted by phone or email to receive more information about the Earn While You Learn program:*

YesNo

My name is Representative and I am picking up for the client because Reason.

Signature

Select the date and time you picked up your items.*

DateHourMinutesAM/PM Option

Healing Hurts Ministries Diaper Bank Request Form