May Diaper Distribution

Diaper Distribution Registration
Registration form

Thank you for your interest in registering for our Diaper Distribution. Due to high demand and limited resources, we are implementing stricter attendance and verification policies to ensure items reach families who need them most. Thank you for your understanding and cooperation.
Your Name*

First NameLast Name
Email Address*
example@example.com
Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Are you registering for yourself?*

Yes, I am the person who will pick upNo (Please STOP and have the individual complete this form themselves.)
Pick-Up Policy Acknowledgment Please confirm the following:(Select all)*

I understand that a valid ID is required at pick-upI understand that the person who registers must be present to receive the itemsI understand that failure to pick up without notice may affect future participation
Pick up only between 3:00 p.m.- 4:30 p.m. If you are unable to pickup during this time we are unable to accomadate you.
What items are you in need of?*

Diapers onlyDiapers and wipesDiapers, wipes, and formula
What size diapers are you need of?*

NewbornSize 1Size 2Size 3Size 4Size 5Size 6
Are you Pregnant?*

YesNo
If yes, please enter your due date.
Do you have a child under 1 year old?*

YesNo
If so please enter your child's birthdate.
How did you hear about us?*

Pregnant with Possibilities Resource Center WebsiteCommunity OrganizationSocial MediaRadioFriends or FamilyOther
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Diaper Distribution Registration