FORM for DIAPER NEED ASSISTANCE

The "BCF" operates a one-stop-shop for local families to become more self-sufficient by connecting vulnerable families to much-needed services in the local community.

The diaper program provides emergency diapering supplies assistance to aid families towards 'self-sufficiency'. The Boniface and Celita Hygiene Pantry understands everyone experience financial hardship and we are here simply to help parents in times of need.

Please Make Sure To:

1. Please complete ALL question on Sections (1 - 6)
on the New Client Diaper Need Application.

SECTION 1: Parent/Guardian Receiving Diapers
SECTION 2: Referral/Organization Agency
SECTION 3: Child(ren) Information
SECTION 4: Confirm Appointment (day and time)
SECTION 5: Diaper Program; Photo and video Understanding
SECTION 6: Diaper Need Agreement and Signature

There is no right or wrong answers. Please answer very question as truthfully as you can. Please note: that all information collected is solely for the use of The Diaper Bank and The National Diaper Bank Network will not be shared or disclosed to any outside person/organizations.

2. Photo or Video understanding

3. Please Initial, Sign and Date application. Parent/Guardian signature required.

4. Questions? Email BonifaceAndCelitaFoundation@GMX.com

WHAT TO BRING ?

A) We require the child(ren) to be present during your first initial visit.

B) We require one form of identification for 'the parent' 'picking' up diapers.
VALID IDENTIFICATION FOR THE PARENT: (current driver's license , state/government issue I.D or military I.D)

and

C) One form of identification for each child receiving diapers.
VALID IDENTIFICATION FOR THE CHILD: (identification with the child birthdate), letter head from child school/child care with parent name and child's name listed, or the child's birth certificate).

Please Note

Our inventory of diapers and supplies are dependent upon donations.
Our distribution amount is affected by our stock and can fluctuate.

SECTION 1
PARENT/GUARDIAN RECEIVING DIAPER

Name of person completing this application:

First NameLast Name

What is your relationship to 'the CHILD' needing diaper assistance ?

Other

Case Worker/ Agency Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Agency Name:

Agency Phone Number:

Area CodePhone Number

Parent is an ?

Name of Parent needing emergency diapering assistance:

First NameLast Name

Parent Date Of Birth

MonthDayYear

Parent E-mail Address:

Parent Phone Number:

Area CodePhone Number

Phone Number listed above: "is my"

What Phone Number Can We Send You Text Messages On? ** We may communication with you and send you correspondence regarding your application (availability status update, confirmation, appointment status, cancellations, etc) by text message **

Area CodePhone Number

I AGREE to receive periodic 'TEXT message(s)' communication from the diaper bank, regarding my application (availability status update, confirmation, appointment status, cancellations, etc)

Parent current Living Arrangements:

Parent current living Address: (NO P.O Box):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Best Method Of Contact:

Other

Have you received diapering supplies from us in the past?

1. What Program(s) the parent currently in?

2. Parent currently in high school?

Current School Grade:

3. Gender:

4. Race:

5. Parent currently working?

6. Name of employer?

7. Are you currently pregnant?

Expected Due Date:

MonthDayYear

8. Expected Child Gender:

9. Are you currently receiving diapering assistance from another program/ organization?

If Yes , from what organization?

10. How many children are you requesting diapering assistance? {We currently have diaper sizes " 2 thru 4 only " ... {Sometimes WE receive Pull-up's and/or Training pants}

11. How many children (under 5 years old) currently living in your household?

12. How will the parent utilize diapering supplies?

Other

13. Do you require translator

14. Primary language spoken at home?

Second language?

SECTION 2
REFERRAL / ORGANIZATION AGENCY

1. Were You Referred by "MIAMI DIAPER BANK" {IF YES COMPLETE Question # 3 }

IF YOU ANSWER "YES" TO QUESTION 1.
PLEASE ANSWER QUESTION three only.
NO NEED TO ANSWER QUESTIONS 4 thru 8

2. Were You Referred by "CARE RESOURCE" {IF YES COMPLETE Question #3 }

IF YOU ANSWER "YES" TO QUESTION 2.
PLEASE ANSWER QUESTION three only.
NO NEED TO ANSWER QUESTIONS 4 thru 8

3. Name 'OF THE PERSON' That Referred You to our "DIAPER BANK PROGRAM"

First NameLast Name

4. Were You Referred by an: Agency or Organization about our "DIAPER BANK PROGRAM"

5. What is the NAME OF ( the: Agency or Organization ) That Referred You about our "DIAPER BANK PROGRAM"

6. What's the PHONE NUMBER ( at: Agency or Organization ) That Referred You to our "DIAPER BANK PROGRAM"

Area CodePhone Number

7. Agency / Organization Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

8. How did you hear about the Boniface and Celita Hygiene Pantry - Diaper Bank Program?

P L E A S E - N O T E

We cannot guarantee all diaper need requests will be fulfill.

We DO NOT accommodate any requests without an appointment

The 'number of diapers AND diaper brand name' provided to parent is based donations the pantry receives from donors and sponsors.

SECTION 3
CHILD(ren) INFORMATION

CHILD #1 INFORMATION

1. Child date of birth

Date

2. Your Relationship to the child

3. CHILD #1 Name

First NameLast Name

4. Child's gender?

5. Current diaper size?

Your 1st and 2nd choices: Diaper brand(s) you typically purchased for this child?

How often and why you primary choose these brand(s) for this child?

Why?

Why you choose these brand(s) for this child?

6. Please select diaper size needed for child #1

~ THIS WILL BE THE DIAPER SIZE THE CHILD WILL RECEIVE ~ **There will be a limit to the number of each size given at distribution** PLEASE NOTE: We often receive many donated baby diaper brands (brand name and generic brand names), varies during distribution. We cannot guarantee the accuracy and name brand of every baby diapers given to parent at each distribution.

Other?

What diaper size is needed for this child that is not listed above?

7. Average # diaper usage (per day) for this child?

How many diapers does this child uses on daily basis

8. Child currently enrolled in any such Daycare/ Early Head Start program?

If so; what program(s)?

9. Child allergic to any baby diaper brands?

If Yes; Explain?

10. Child allergic to any baby wipes brands?

If Yes; Explain?

11. Does this child have Special Needs / Developmental delay or any Disabilities?

Other

Special Needs / Developmental delay or any Disabilities? If Yes; Explain?

Put NO: IF THIS CHILD DO NOT HAVE: Down syndrome, autism, dyslexia, chronic asthma, ADHD, epilepsy, ADD, multiple sclerosis, bi-polar, etc

CHILD #2 INFORMATION

1. Child date of birth

Date

2. Your Relationship to the child

3. CHILD #2 Name

First NameLast Name

4. Child's gender?

5. Child currently enrolled in any such Daycare/ Early Head Start program?

If so; what program(s)?

6. Current diaper size?

Your 1st and 2nd choices: Diaper brand(s) you typically purchased for this child?

How often and why you primary choose these brand(s) for this child?

Why?

Why you choose these brand(s) for this child?

7. Please select diaper size needed for child #2

~ THIS WILL BE THE DIAPER SIZE THE CHILD WILL RECEIVE ~ **There will be a limit to the number of each size given at distribution** PLEASE NOTE: We often receive many donated baby diaper brands (brand name and generic brand names), varies during distribution. We cannot guarantee the accuracy and name brand of every baby diapers given to parent at each distribution.

8. Average # diaper usage (per day) for this child?

How many diapers does this child uses on daily basis

9. Child allergic to any baby diaper brands?

If Yes; Explain?

10. Child allergic to any baby wipes brands?

If Yes; Explain?

11. Does this child have Special Needs / Developmental delay or any Disabilities?

Other

Special Needs / Developmental delay or any Disabilities? If Yes; Explain?

Put NO: IF THIS CHILD DO NOT HAVE: Down syndrome, autism, dyslexia, chronic asthma, ADHD, epilepsy, ADD, multiple sclerosis, bi-polar, etc

SECTION 4
CONFIRM YOUR APPOINTMENT

WHAT TO BRING ?

A) We require the child(ren) to be present during your first initial visit.

B) We require one form of identification for 'the parent' 'picking' up diapers.
VALID IDENTIFICATION FOR THE PARENT: (current driver's license , state/government issue I.D or military I.D)

and

C) One form of identification for each child receiving diapers.
VALID IDENTIFICATION FOR THE CHILD: (identification with the child birthdate), letter head from child school/child care with parent name and child's name listed, or the child's birth certificate).

IF YOU CAN NOT MAKE YOUR APPOINTMENT:

1) We do require families contact us if they are not going to be able to make their scheduled distribution. Families that "no show" without a phone call, text or email must wait an additional MONTH before receiving diapers for the first no show.

2) After the 2nd no-shows families will no longer be eligible to receive supplies.

3) We require 24 hours advanced notice of need to reschedule/cancel an appointment, or families will be asked to wait 2 weeks for assistance

PLEASE NOTE: We cannot accommodate any requests without an appointment.

SECTION 5

PLEASE NOTE:

Our inventory of diapers and supplies are dependent upon donations.
Our distribution amount is affected by our stock and can fluctuate.

Photo and Video Understanding

Parent/Guardian consent to take random photography and/or video

PLEASE READ
Boniface and Celita Hygiene Pantry mission is to raise awareness for diapers need and hygiene essentials. “A picture is worth a thousand words.”

Our donors, supporters, and sponsors often visit our social media, photo’s, video’s and our website to view our nonprofit’s photo essay. Our photo essay puts a face to the message that our nonprofit serve, and tell the personal story of those who are benefited from our services.

Thanks to our donors, supporters and sponsors generosity, their donations allow us to continue assisting those in our community.

The reason we request the parent/guardian consent to random photography and/or video of the parent and their child(ren), so that our donors, supporters, and sponsors see that their donation is going directly to those that are in need.

1. Still Photographs: (photo's)

"I" the parent/guardian
"IS AWARE" that photograph(s) of myself "I" the parent and my child(ren) to be viewed by the Boniface and Celita Hygiene Pantry sponsor, partners, donors, and funders. I agree to the display of still photo(s) on the Hygiene Pantry website, newsletter, social media outlet(s).

1. I under that random photo(s) of myself and my child(ren) maybe taken at time of distribution and that these photographs maybe used to promote the purposes of The Boniface And Celita Hygiene Pantry with no compensation due to me

Other

Any questions, comments, suggestions, issues, worries, concerns, ect?

Any issues you may have regarding Hygiene Pantry using still photo footages of you and your child(ren) ?

2. Video

"I" the parent/guardian
IS AWARE: that video of "myself" I the parent and my child(ren) to be viewed by the Boniface and Celita Hygiene Pantry sponsor, partners, donors and funders. I agree to video on the Hygiene Pantry website, newsletter, social media outlet(s)

2. I understand that video of myself and my child(ren) maybe taken at time of distribution and that these photographs maybe used to promote the purposes of The Boniface And Celita Hygiene Pantry with no compensation due to me

Other

Any questions, comments, suggestions, questions, comments, issues, worries, or concerns, ect?

Any issues you may have regarding Hygiene Pantry using video footage of you and your child(ren) ?

SECTION 6
Diaper Need Agreement and Signature

1. Parent/Guardian agree to receive diapers/diapering supplies and or hygiene items in an ethical, conscient Boniface and Celita Hygiene Pantry - Diaper Bank may be sold, returned, exchanged, traded, bartered, used as a gift, for fundraising, auctions or raffles. Items may only be used to provide personal services to the parent/guardian of the child.

Do you do fully comprehend everything you read in question 1?

2. Parent/Guardian “I” hereby indemnify, defend and hold Boniface and Celita Hygiene Pantry, Center For Advancement Of Girls And Women, The Miami Diaper Bank, any/all our suppliers, donors, sponsors, directors and/or employees, partners and National Diaper Bank Network from any and all liabilities for the quality, recall or safety of the product (the “Product”), consisting of diapers, infant-toddler essentials, hygiene assistance, and incontinence items received as donations or purchased by the Hygiene Pantry and then donated by The Hygiene Pantry.

“I” hereby forever release and discharge The Boniface and Celita Hygiene Pantry, Center For Advancement Of Girls And Women, The Miami Foundation, any/all our suppliers, donors, sponsors, directors and/or employees, National Diaper Bank Network, its officers, volunteers, sponsors, partners, donors, directors and/or employees from any and all claims for any known, unknown or future damages, because of the quality or safety of the Product/items.

Do you do fully comprehend what you read in question 2?

3. Parent/Guardian acknowledges that Hygiene Pantry receives diapers donated by others; that Hygiene Pantry often receives donations of loose diapers or opened packages of diapers, clothing and children essentials; The Hygiene Pantry also purchase new diapers; and that Diaper Bank donates diapers, hygiene items with no consideration received. Although the Hygiene Pantry believes, to its best knowledge, that donation of baby diapers, children items, from donors are safe, The Hygiene Pantry has inspected diapers, and hygiene items to the best of our knowledge, for safety- cleanness and other matters. It is the responsibility of Parent/Guardian prior to leaving Boniface and Celita Hygiene Pantry, Center For Advancement Of Girls And Women, any of our events- to inspect the diapers, children essentials, and hygiene items as received.

Do you do fully comprehend what you read in question 3?

I certify that the information given on this assessment is accurate.
Please note that all information collected is solely for the use of The Hygiene Pantry, Center For Advancement Of Girls And Women and The National Diaper Bank Network will not be shared or disclosed to any outside person/Organizations

By signing below, the parent agrees to the terms listed above:

WHAT TO BRING WITH YOU WHEN PICKING UP DIAPERING SUPPLIES:

A) We require the child(ren) to be present during your first initial visit.

B) We require one form of identification for 'the parent' 'picking' up diapers.
VALID IDENTIFICATION FOR THE PARENT: (current driver's license , state/government issue I.D or military I.D)

and

C) One form of identification for each child receiving diapers.
VALID IDENTIFICATION FOR THE CHILD: (identification with the child birthdate), letter head from child school/child care with parent name and child's name listed, or the child's birth certificate).

Thanks to our donors, supporters and sponsors generosity, their donations allow us to continue assisting those in our community.

Our donors, supporters, and sponsors often visit our social media, photo’s, video’s and our website to view our nonprofit’s photo essay.

THE REASON WE ASK the parent/guardian voluntarily consent to photography and/or video of the parent and their child(ren) because:

Our inventory of diapers and supplies are dependent upon donations. Our distribution amount is affected by our stock and can fluctuate.

We cannot guarantee all diaper need requests will be fulfill.

We DO NOT accommodate any requests without an appointment

The 'number of diapers AND diaper brand name' provided to parent is based donations the pantry receives from donors and sponsors.

“I” Parent/Guardian acknowledges the Hygiene Pantry receives diapers donated by others; “Parent/Guardian” acknowledges the Hygiene Pantry may not provide “Parent/Guardian” with the name brand diapers/diapering supplies parents typically purchase for their child.

Select one:

Other

Name of Authorized Adult who can Pick up diapers for this Child (must be over 18yrs old & provide ID)

First NameLast Name

"Gender" of Authorized Adult (must provide ID)

What is your relationship to 'the Parent' requesting emergency diaper assistance ?

Other

Initials of Person completing this form:

If parent is UNDER 18 years old.

Name of Person completing this form on behalf of the parent (if parent is an "Adolescent" (Under 18 years old)

First NameLast Name

All ‘survey’ questionnaire will be kept in a secure manner and not released to any external organization other than in aggregate for grant funding, donors, demographic and audit purposes.

DIAPER NEED APPLICATION