Registration Form
2026/2027
Student Name
*
First Name
Last Name
Student DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Ethnicity
*
Please Select
Native American
Hispanic
African American
Caucasian
Asian/Pacific Islander
Other
Preferred Language
Please Select
English
Spanish
Other
Do you agree to receive text message communications regarding this program?
Please Select
Yes
No
How did you hear about Diapers For Diplomas?
Have you participated in this program before?
*
Yes
No
Are you currently receiving services through The Jeremiah Program?
Yes
No
Are you currently experiencing financial difficulties related to diaper costs?
Yes
No
Do you require any disability-related accomodations?
No
Yes
If yes, please explain
Please select your Medicaid provider.
Please Select
Anthem
United Healthcare Health Plan of Nevada
Silversummit Healthplan
Molina Healthcare
CareSource
Emergency Medicaid
I don't receive Medicaid
College/University Information
College/University Currently Enrolled
*
Please Select
NSU
UNLV
CSN
UNR
TMCC
DRI
GBC Pahrump
Full Time or Part Time
*
Full Time
Part Time
Estimated Graduation Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Major/Field of Study
*
Submit Proof of Enrollment for Fall 2026
*
Browse Files
(class schedule that includes your name)
Cancel
of
Child Information
Child's Name
Child's DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Browse Files
Cancel
of
Register
Should be Empty: