Current Little Lambs Diaper Bank Client Application

Little Lambs Diaper Bank Client Application

Please Note: Due to a high number of requests for assistance, it may take up to 7 days to process your application. You will be notified via text of your application status.
Your Name*

First NameLast Name
Spouse or Live-In Partner Name

First NameLast Name
Todays Date*

MonthDayYear
Date
Email*
example@example.com
Address*
City*
Phone Number That Can Receive Texts *
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
Your Place of Employment*
Your Hourly Pay$*
Your Hours worked per week*
Your Monthly Gross Income $*
Monthly Gross Income (Required): Please provide your total hourly income. This should include all income sources such as wages, salary, unemployment benefits, seasonal work, and any other income from adult individual living in the home.
Spouse or Live-In Partner Place of Employment
Spouse or Live-in Partner Hourly Pay $
Spouse or Live-in Partner Hours worked per week
Spouse or Live-in Partner Monthly Gross Income $
Monthly Gross Income (Required): Please provide your total hourly income. This should include all income sources such as wages, salary, unemployment benefits, seasonal work, and any other income from adult individual living in the home.
Which Benefits does your household currently receive?*

SnapWicTanfMedicaidHousing AssistanceUnemploymentSocial SecurityWorkers CompensationFood StampsDisabilityType option 11Other
Are you in need of a referral for other services ie: Food, rental assistance, domestic violence shelter, Etc. *
Do you receive diapers from another organization?*

YesNo
Are you pregnant?*

NoYes , When is your due date?
How many children living in household:*
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 Spoken*
I am a Current Foster Parent*

YesNo
Are you or your spouse or Live-In partner a student?*

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

YesNo
I am asking for assistance from Little Lambs because:*
Wic or Snap Benefit Letter*

Cancelof
Person Applying For Diapers Pay Stub *

Cancelof
Spouse or Live-In Partner Pay Stub

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*
I understand that it is prohibited to sell, barter, or trade any items received from Little Lambs Foundation for Kids. If you have extra diapers that you are not using that you receive from Little Lambs, please return to Little Lambs so another qualified family can receive them.*
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*
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*
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*
I understand that Little Lambs Foundation for Kids only assists with diapers up to the age of 36 months. Initial Below*
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*
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*
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*
By signing I release Little Lambs Foundation for Kids and its board members, volunteers, officers, employees, and agents from any and all liability. Signature*