Current Little Lambs Diaper Bank Client Application

Little Lambs Diaper Bank Client Application
Name*

First NameLast Name
Spouse or Partner Name

First NameLast Name
Todays Date*

MonthDayYear
Date
Email*
example@example.com
Address*
City*
Phone Number*
Marital Status / Household Living Status*

MarriedSingleSeparatedLive in PartnerMultiple Family Residence
How many adults living in household:*
Current Employment Status ( check all that apply)*

Employed full-timeEmployed part-timeMutliple jobsSelf-employedCurrently unemployedUnable to work due to disabilty
Do you currently have at least one working adult living in your home?*

YesNo
Hours Worked per week?*
Hourly Wages?*
Monthly Gross Household Income (Required): Please provide your total annual or hourly household income. This should include all income sources such as wages, salary, unemployment benefits, EBT, SSI, workers’ compensation, seasonal work, and any other income from all individuals living and working in the home.*
If you answered 0 on previous question please explain in detail :
Which Benefits does your household currently receive?*

SnapWicTanfMedicaidHousing AssistanceNone
Do you receive diapers from another organization?*

YesNo
If you answered yes on previous question does it fully meet your diaper needs?*

YesMostlyNo
How many children living in household:*
Are you pregnant?*

NoYes , When is your due date?
Child(ren) Name, Gender, and Birthdate of Child(ren) UNDER 36 Months Old.
Child Name # 1 *
Date Of Birth*
Child Gender*

MaleFemale
Child Name # 2
Date of Birth
Child Gender

MaleFemale
Child Name #3
Date Of Birth
Child Gender

MaleFemale
Little Lambs hosts several events throughout the year that may be suitable for older children. If you would like to be notified about future opportunities, please provide your child's name and date of birth, and we’ll be sure to keep you informed about any upcoming events. Would you like us to contact you about these opportunities?*

YesNo
Name

First NameDate Of Birth
Name

First NameDate Of Birth
Name

First NameDate Of Birth
Name

First NameDate Of Birth
How did you hear about our program*
Ethnicity/Race*

American Indian/Alaskan NativeAsianBlack or African AmericanHispanicNative Hawaiian or Other Pacific IslanderWhiteTwo or More Races (Multi Racial Individuals)
Native Language*
I am a Current Foster Parent*

YesNo
Are you or your spouse or partner a student?*

NoYes, If Yes , List School Name Below.
Low-Income*

YesNo
I am asking for assistance from Little Lambs because:*
Are you in need of a referral for other services ie: Food, rental assistance, domestic violence shelter, Etc. *
Proof of Income, EXAMPLE: Copy of Wic Certificate(WIC CARD NOT ACCEPTED) Snap Benefit Letter , Unemployment Statement, Letter From Employer or Last 2 Months Pay Stubs For ALL INDIVIDUALS WORKING IN THE HOME*

Cancelof
Baby Birth Certificate or Foot Print Card For Each Child Under 36 months old Receiving Diapers*

Cancelof
Picture of Photo Identification for Parent , or Passport*

Cancelof
I Understand DIAPERS WILL ONLY BE AVAILABLE TO PICK UP ON TUESDAYS & WEDNESDAYS 10 AM-1 PM & THURSDAY from 4-7 PM Initial Below*

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I understand that it is prohibited to sell, barter, or trade any items received from Little Lambs Foundation for Kids. This includes but is not limited to exchanging for money, products, and services, or using items for fundraisers, raffles, auctions, or any other purpose. Initial Below*

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I understand that Little Lambs Foundation for Kids is a program to assist foster children and low-income families with the goal of working towards self-sufficiency. Initial Below*

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I understand that Little Lambs Foundation for Kids operates off of donations from the community and is unable to provide any specific brand request for diapers. There are no exceptions for any reason. Initial Below*

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I agree not to ask or request extra items from Little Lambs Foundation for Kids. If extra items are available they will be offered during diaper distribution times. Initial Below*

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I understand that Little Lambs Foundation for Kids only assists with diapers up to the age of 36 months. Initial Below*

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By signing I agree that I may be asked to show proof of income at any time. Failure to comply with the Little Lambs Diaper Bank Client Agreement will terminate any further assistance from Little Lambs Foundation for Kids. Initial Below*

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I understand Little Lambs operates off of donations from our community. Little Lambs will make every effort to assist families but cannot guarantee all diaper requests will be fulfilled. Initial Below*

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I understand that videos and photos of myself and my children may be taken at the time of distribution and that they may be used to promote the Little Lambs Diaper Bank program with no compensation due to me. Initial Below*

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By signing I release Little Lambs Foundation for Kids and its board members, volunteers, officers, employees, and agents from any and all liability. Signature*

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