Mobile Pantry Registration - Youth & Adult Incontinence Products

Mobile Pantry Registration - Youth & Adult Incontinence Products

Distribution Policy & Intake Form
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 products.

Individuals 65 years of age and older automatically qualify for the program. Please bring your Medicare and/or Medicaid card with you to your first visit. You can also upload it to this registration form. Be sure to bring a photo ID to your first visit.

For individuals 5-64 years old and/or with special needs, the following documents must be provided at your first visit:

1. Photo ID (caregivers must provide ID for themselves and the recipient of the supplies)

2. Proof of date of birth

3. Prescription of incontinence or IEP/doctor's note with diagnosis

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.

Incontinence products 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 individual/guardian/caregiver at every visit (driver's license, state ID, military ID, passport, VISA) to a mobile distribution. Additional documentation (birth certificate, Medicare/Medicaid card, proof of diagnosis, prescription, etc.) can be uploaded to this form. If you choose not to upload documents to this form, please bring them with you 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*
E-mail*
example@example.com
How did you hear about us?*
Please Specify*
Date of Birth:*
Gender:*

MaleFemale
Marital Status:*

SingleMarriedDivorcedSeparatedWidow
Race:*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic / LatinoNative Hawaiian or Other Pacific IslanderWhiteOther
Do you have insurance?*

MedicareMedicaidHMOPPOOtherNone
Are you receiving help with briefs and/or incontinence products from other agencies?*

YesNo
If yes, which agencies? Please list them. If none, please type N/A.*
Please upload documentation here (birth certificate, proof of birth, Medicare/Medicaid card, doctor's diagnosis, prescription, IEP, etc.). If you choose not to upload documents, please bring them with you to your first visit.

Cancelof
What is your relationship to the person completing this registration form?*

SelfParentGrandparentLegal GuardianCaregiverFamily MemberOther
Demographic Information
What size briefs do you typically need and purchase?*

Youth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult X-LargeAdult 2XL
Are you in need of other products? Select all that apply.*

Bed PadsPoise Pads (Women)Guards (Men)None
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 currently looking for work?*
How many adults in your household are students?*
Are you a veteran or 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 incontinence products and buying something else you/your family needed?*

YesNo
Receiving incontinence products will allow me and/or my family to (check all that apply):*

Send a child to daycare or other programsReduce my stressLook for workMake my child happierGo to workBuy foodHelp my child to be healthierGo to job trainingPay a billBuy clothingBuy non-food items like toothpaste, soap, or toilet paperStay clean, dry, and healthyHave a better quality of lifeAvoid being homebound
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 forms, and forms that are missing the required uploaded documentation, will not be accepted.
I have read and agree to the incontinence product distribution policy as outlined above.*

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

YesNo
I understand that if I attempt to sell the products 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
Type your full name: *
Type your initials:*
Date:*

MonthDayYear
Date
Should be Empty:

Mobile Pantry Registration - Youth & Adult Incontinence Products

Demographic Information