Ground & Root Diaper Grant Eligibility Verification Form
Please fill out the following information to verify your eligibility for the grant.
Full Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Are you currently employed?
Yes
No
Annual Income Range
Please Select
Less than $20,000
$20,000 - $40,000
$40,001 - $60,000
$60,001 - $80,000
More than $80,000
Are you a resident of the area where the grant is offered?
Yes
No
Which county do you currently reside?
How did you hear about this grant?
Social Media (FB, IG, Threads)
Community Resource Center
Website
Other
What size diaper(s) are you CURRENTLY in need of?
I understand that I may only apply for the Ground & Root Pelvic Floor Therapy Diaper Grant once a quarter.
I understand
I understand that I am responsible for picking up of the diapers from the Diaper Bank location
I understand
I understand that if I am approved, I will receive a package based on the age and weight of the child/children I have applied for.
I understand
I understand that Ground & Root Pelvic Floor Therapy Diaper Grant is unable to honor requests for specific brands, styles, and that I am not guaranteed gender-matched colors/prints.
I understand
I understand that I will receive communications via email from Ground & Root Pelvic Floor Therapy Diaper Grant , including the full recipient agreement and program terms. I understand that I will need to respond before diapers can be distributed to me.
I understand
I understand that Ground & Root Pelvic Floor Therapy Diaper Grant may conduct a search to verify aspects of my application. This includes whether I have received diapers from other sources, as well as my social media activity and feedback. I understand that I will have an opportunity to appeal any denial of my application as a result of this search.
I understand
I agree that all the information contained in this application is truthful, complete, and accurate.
I agree
Signature
Submit
Should be Empty: