Undercover Pantry Sign Up

1
Full Name of Caregiver* This field is required.The caregiver who will be picking up the products.
First Name
Last Name
2
Caregiver Email* This field is required.We will email you a confirmation of your sign up.
example@example.com
3
Caregiver Phone Number* This field is required.
Area Code
Phone Number
4
Home Zip Code* This field is required.The zip code of the home you reside in.
5
Preferred Contact Method* This field is required.How would you like for us to contact you?
Phone Call
Text Message
Email
Other
6
Child 1: First Name & Date of Birth :* This field is required.Enter "N/A" if you are only requesting menstrual items.
First Name
Date of Birth
7
What size diapers do they need?Please note, we do not have pull-ups at this time. Enter "N/A" if you are only requesting menstrual items.
8
What size diapers does Child 1 need?* This field is required.Please note we can only serve 2 children per household at this time.
Preemie
Newborn
Size 1
Size 2
Size 3
Size 4
Size 5
None
Other
9
Child 2: First Name & Date of Birth Select "Next" if you do not need diapers for a second child.
First Name
Date of Birth
10
What size diapers does Child 2 need?* This field is required.Please note we can only serve 2 children per household at this time.
Preemie
Newborn
Size 1
Size 2
Size 3
Size 4
Size 5
None
Other
11
What size diapers do they need?Please note we do not have pull-ups at this time. Select "Next" if you do not need diapers for a second child.
12
Where would you like to pick up?
Please Select
1000 Chicago Avenue in Harrisonburg
475 Lee Jackson Highway in Staunton
500 1st Street in Shenandoah
13
Who will usually pick up the diapers?
Me
Someone else
14
Who is authorized to pick up your diapers?This helps us know who is authorized to pick up on your behalf.
15
Do you receive diapers from any other diaper program or pantry?
YESNO
16
If yes, please list which diaper program or pantry
17
Do you also need menstrual products?
YESNO
18
For how many people?We can currently serve up to two people per household. Please answer honestly to help us manage inventory and reach more families.
12
19
What type(s) of products would you prefer?Product types and sizes are filled as supplies allow. We’ll make every effort to provide your preferred items when possible.
Pads
Tampons
Liners
Menstrual cups
Unsure / No preference
Other
20
If we don’t have your selected product available, would you like us to substitute a similar item?(for example, pads instead of tampons)
Yes (Substitutions are fine) No, thanks I'd rather wait.
21
Right now, we’re able to offer diapers, wipes, and menstrual products.You can list anything that would make life a little easier for your household—like food, clothing, help with bills, or community programs you wish existed.
22
What day and time usually work best for pickup?We’ll do our best to match your preference based on volunteer and inventory schedules.
23
I confirm the information provided is true to the best of my knowledge.
YESNO
24
You confirm that the information you’ve shared is true and that all items requested are for individuals who live in your household. If false information is provided, participation may be discontinued. The Undercover Pantry depends on honesty to make sure supplies reach families who truly need them.
Yes, everything is trueNo, I need to cancel my sign up
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