Little Lambs Diaper Bank Client Agreement (1)

Little Lambs Diaper Bank Client Agreement

Name*

First NameLast Name

Date*

Date

Email*

example@example.com

Address*

City*

Household Annual or Hourly Income Amount (Required): This includes , EBT , Unemployment Insurance, Workers Comp, Wages, Salary, SSI Benefits, Seasonal etc.*

How Many Children Living in household:*

Phone Number*

Maried or Single*

MarriedSingle

How Many Adults Living in household:*

Child(ren) Name, Gender, and Birthdate receiving Diapers

Child Name # 1 *

Child Gender*

MaleFemale

Date Of Birth*

Child Name # 2

Child Gender

MaleFemale

Date of Birth

Child Name #3

Child Gender

MaleFemale

Date Of Birth

How did you hear about our program*

Ethnicity/Race*

Native Language*

I am a Foster Parent*

YesNo

I am a Student*

YesNo

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 , Snap Benefit Letter , Unemployment Statement, Letter From Employer or Last 2 Months Pay Stubs*

Baby Birth Certificate or Foot Print Card For Each Child Receiveng Diapers*

Picture of Photo Identification, or Passport*

By signing 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. 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. Little Lambs does not trade diapers or take diaper brand requests. Please do not request extra items, if items are available they will be offered to you during diaper distribution times. I also understand Little Lambs operates off donations from our community and cannot guarantee all diaper requests will be fulfilled. 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. I understand that Little Lambs assists with diapers up to the age of 3. By signing | acknowledge 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. By signing I release Little Lambs Foundation for Kids and its board members, volunteers, officers, employees, and agents from any and all liability.

Signature

DIAPERS WILL ONLY BE AVAILABLE TO PICK UP ON TUESDAYS & WEDNESDAYS 10 AM-1 PM & THURSDAY from 4-7 PM