Diaper Bank Inquiry Form

Diaper Bank Inquiry Form

Please fill out the form below to inquire about the Healthy Steps Diaper Bank diaper donation and distribution services.
Family Promise HCR is a case management site for Healthy Steps Diaper Bank.

Please note: Diaper pickup dates are assigned after your order is placed, and Family Promise HCR is not responsible for selecting pickup dates. Distribution dates are the first and third Tuesday of the month.

Pickup Location:
56 Erford Road
Camp Hill, PA 17011

To ensure a staff member is available, please email to schedule your pickup time:
Stacey@familypromisehcr.org | Christine@familypromisehcr.org
Please fill out one application per child
Parent/Guardian Full Name*

First NameLast Name
Parent/Guardian Date of Birth

MonthDayYear
Date
Relationship to Child

MotherFatherStep MotherStep FatherGrandparentOther RelativeNo relationshipFoster Parent
Military Status

Non-Military / SpouseActive Military / SpouseRetired / SpouseReserve / SpouseNational Guard / Spouse
Email Address*
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Child Full Name

First NameLast Name
Childs Date of Birth

MonthDayYear
Date
Diaper or Pull-Up

DiaperPull Up
Diaper Size - client will receive 50

PreemieNewbornSize 1Size 2Size 3Size 4Size 5Size 6Size 7
Pull Up Size - client will receive 40 *Pull-ups not available for ages 2 and younger*

2T-3T3T-4T4T-5TL/XL
Childs weight if receiving a pull-up
Allergies to a certain brand of diaper/pull-up?
Race

American Indian or Alaska NativeAsianBlack or African AmericanWhiteTwo or More RacesOther
Gender

MaleFemale
Ethnicity

Hispanic or LatinoNon-Hispanic or Latino
Currently potty training?

YesNo
Currently receiving WIC?

YesNo
To provide you with the best service possible, Family Promise Harrisburg Capital Region will keep track of the services and support we provide to you and your household. This also allows us to advocate for you better and properly connect you with resources. To do this, your information will be stored securely and only accessible to authorized Family Promise staff and program partners who are directly involved in helping meet your needs. Your information will not be shared with outside agencies or individuals without your permission, except as required by law.
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Diaper Bank Inquiry Form

Please fill out one application per child