AOK Emergency Diaper Program Registration Form

AOK Emergency Diaper Program Registration Form

Emergency need only. For your immediate family.
This program is being brought to you by Act On Kindness in partnership with First 5 Sacramento.

We do ask that you have a true emergency need and are suffering a financial hardship to request items. That way we can help families who need it the most. 🙏

Please note:

You can only utilize this service once every 30 days. Please fill out a form for each child.

You must live in Sacramento County. Pickup is in Sacramento, cross street is Don Julio / Elkhorn.

We cannot guarantee to have items on hand and will do our best to help in a timely fashion.

If we can not help you, we can provide you with other program information that has similar items.

Thanks you for patience and understanding as we roll out this new program. 🙏

*We do not share your personal information. You may be emailed to verify information and also contacted via text message to arrange pickup.

Please do not call before 8am or after 8pm. M-Sun.
Parent/Guardian Full Name

First NameLast Name
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Child's Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Household Income
What item(s) are you in need of. Please only request what you actually need. 🙏
Please give detailed information as to what size diapers, formula brand, any allergies, etc.
Where did you hear about our program?
What is your name on Facebook?
Should be Empty: