Infant Resource Membership Form

I understand that participation in these services is completely voluntary and that I may withdraw my participation at any time.ConfidentialityI understand that the information I provide will be kept confidential to the extent permitted by law. My information will only be shared with trusted community partners or service providers when necessary to coordinate services, provide referrals, verify eligibility, or comply with legal requirements.By signing below, I acknowledge that I have read and understand this consent form and agree to participate in services provided by the Shades of Motherhood Network.

Consent for Services: I voluntarily consent to receive support and care services through the Shades of Motherhood Network and its affiliated programs. I understand that services may include, but are not limited to: Peer support services

Communication Consent: consent to being contacted by the Shades of Motherhood Network through ( Four attempts will be made for the family to provide care. Phone Calls are Highly recommended)

Primary Guardians Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Guardians Date of Birth

Date

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Where did you hear about this Resource?

Do you have Medicaid?

Childs Full Name

First NameLast Name

Date of Birth of Child

Date

I am partnered with a diaper spot.

My Doula Is

Please upload one of the following documents as proof of birth:Birth certificateOfficial mail showing the child's first and last nameChild's insurance card or insurance identification documentOther proof of birth documentationIf you do not have any of these documents, we can connect you with one of our trusted community partners who can assist with verification.

Diaper Size for Child

What types of Wipes are safe for your Child?

How do you feed your baby?

If you need formula/ What type of Formula can your baby use?

Please know that we may not always have formula, but this will ensure we know what types you can receive if you are not present for pick up of supplies. Type: "Not Needed" if you don't need Formula.

Clothing: All clothing are used

Name of Trusted Pick up Person (Outside of listed Guardian) #1

First NameLast Name

Name of Trusted Pick up Person (Outside of listed Guardian) #2

First NameLast Name

Name of Trusted Pick up Person (Outside of listed Guardian) #3

First NameLast Name

If you have a Doula, put their information here

First NameLast Name

Is there anything else you feel we need to know?

Release of Information

Diaper Bank Client Acknowledgment & Liability Waiver

The Shades of Motherhood Network is committed to supporting families by providing diapers, wipes, and other baby essentials through donated and purchased products. Many of the items distributed through our diaper bank are donated by community partners, organizations, and individuals.
By accepting products from the Shades of Motherhood Network Diaper Bank, I acknowledge and understand the following:
• Products may include a variety of brands, materials, fragrances, and ingredients that could potentially cause allergic reactions, skin irritation, or sensitivities in some children or individuals.
• It is my responsibility to inspect all products before use and discontinue use immediately if any reaction or concern occurs.
• The Shades of Motherhood Network does not manufacture the products distributed and cannot guarantee the condition, ingredients, or suitability of donated items for every child.
• I understand that participation in the diaper bank program is voluntary.
• I agree to release, waive, and hold harmless the Shades of Motherhood Network, its staff, volunteers, partners, sponsors, and affiliates from any liability, claims, damages, injuries, allergic reactions, or losses that may result from the use of products received through the diaper bank program.
• The Shades of Motherhood Network will support families to the best of our ability and address concerns compassionately; however, we are not medically liable for reactions, injuries, or outcomes associated with the use of distributed products.

I,Guardians Initals* acknowledge that I have read and understood this agreement and voluntarily accept products from the Shades of Motherhood Network Diaper Bank.

Guardians Printed Full Name

Signature

Date Signed

Date

Infant Resource Membership Form

Proof of Child

Diapers and wipes

Nutrition

Clothing

List of Trusted Pick-Up People