Mobile Pantry Registration - Baby Diapers & Training Pants

Registration is required at least 24 hours prior to your first visit to any mobile pantry distribution day. On-site and/or same-day registration is not available. If you are not on our registration list when you arrive at a distribution, we will be unable to give you diapers or training pants.

Diapers are provided for children up to age 3. Training pants (pull-ups) are provided for children up to age 4. Once a child turns 4, they are no longer eligible for diapers through our program unless they have an IEP and/or doctor's note stating special needs. Documentation can be uploaded to this form.

Individuals and families can visit our mobile pantry once a month. Our program is not designed to be the sole source of support for an individual or family, but rather to supplement what they can provide for themselves. We strive to assist our community members in their journey to self-sufficiency.

Diapers and training pants are only distributed on the designated mobile distribution days. The distribution schedule, including dates, times, and locations, can be found on our website at https://www.keepingfamiliescovered.org/get-help.

Photo ID is required for the parent/guardian at every visit (driver's license, state ID, military ID, passport, VISA) to a mobile distribution. A birth certificate is required for any child in need of diapers/training pants and can be uploaded to this registration form. If you choose not to upload the birth certificate(s) to this form, you will need to bring them to your first visit to our mobile pantry in order to receive diapers. If you do not have your child's birth certificate, you can upload an alternative form of documentation with the child's name and date of birth (passport, WIC paperwork, guardianship documentation, doctor visit summary, etc.) or bring it to your first visit.

Contact Information

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Format: (000) 000-0000.

E-mail*

example@example.com

How did you hear about us?*

Please Specify*

Marital Status:*

Race:*

How many of your children are in diapers or training pants?*

We do not provide diapers to expectant mothers or unborn children. Once you deliver and can provide proof of your child's birth, you can register for our program.

Diapers are provided for children up to age 3. Pull-ups/training pants are provided for children up to age 4. Once a child turns 4, they are no longer eligible for diapers through our program unless they have an IEP and/or doctor's note stating special needs. Documentation can be uploaded to this form.

Please list the names and ages of all children that need diapers or training pants with their current sizes. *

Please upload a copy of the birth certificate for each child that needs diapers or training pants. If you do not have the certified copy of the child's birth certificate, the certificate issued by the hospital is sufficient until you receive the certified copy. Proof of birth is required for our program. If you choose not to upload the document(s), you must bring them to your first visit to our pantry in order to get diapers.

If you do not have your child's birth certificate, please upload alternative documentation with the child's name and date of birth here (passport, WIC paperwork, guardianship documentation, doctor visit summary, insurance card, etc.). Proof of birth is required for our program. If you choose not to upload the document(s), you must bring them to your first visit to our pantry in order to get diapers.

If any of your children are over the age of 4 and have special needs that require them to be in diapers or training pants, please upload documentation from the child's doctor or IEP here. Documentation for children over the age of 4 is required for our program. If you choose not to upload the document(s), you must bring them to your first visit to our pantry in order to get diapers.

What is your relationship to the child(ren) listed above?*

Are you receiving help from other agencies and/or organizations?*

YesNo

If yes, which agencies and/or organizations are helping you?

What size diapers or training pants do you typically buy for your children?*

How many adults are in your household?*

How many adults in your household currently work outside of the home?*

What is the total annual income for your household?*

How many adults in your household are parenting at home (stay at home parents who are not working outside the home or looking for other work)?*

How many adults in your household are currently looking for work?*

How many adults in your household are students?*

Are you a military family?*

YesNo

Is anyone in your household eligible for WIC, SNAP, or food stamps?*

YesNo

In the past year, have you had to make a choice between buying diapers and buying something else your family needed?*

YesNo

Receiving diapers will allow my family to (check all that apply):*

Would you like information about additional community resources that might be available to you?*

YesNo

Keeping Families Covered reserves the right to refuse service to an individual and/or family if they do not adhere to the program guidelines as outlined, or if any information submitted on this form is found to be false or inaccurate. Incomplete registration forms and forms that are missing the required uploaded documentation will not be accepted.

I have read and agree to the diaper distribution policy as outlined above.*

YesNo

I understand that the diapers I receive from Keeping Families Covered are donated and cannot be sold.*

YesNo

I understand that if I attempt to sell the diapers that are donated to me by Keeping Families Covered via Facebook marketplace or any other way, I will no longer be eligible for service.*

YesNo

I understand that if I attempt to sell the diapers that are donated to me by Keeping Families Covered, the organization will take the appropriate action to recover the diapers and report you to the authorities.*

YesNo

Type your full name: *

Type your initials:*

Date:*

Date

Mobile Pantry Registration - Baby Diapers & Training Pants

Demographic Information