RETURNING APPLICANTS: DIAPER NEED Form  

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.

Returning clients must complete the Returning Parent Questionnaire
EACH TIME prior to receiving diapering and or hygiene essentials distribution.
The data from these application will be entered into the diaper bank online agency portal database for each client serviced by the organization.

DIAPER BANK PROGRAM
The Boniface and Celita Foundation understands everyone experience financial hardship and we are here simply to help in those times of need.

The diaper program provides bi-weekly emergency diapering supplies..

Please note: Typically emergency diaper supplies, sustain the child for a couple of days and in some cases for up to a week.

PLEASE MAKE SURE TO:

1. Please complete ALL question on Sections (1 - 6)
on the Returning Parent Diaper Request Order application.

SECTION 1: Parent/Guardian Receiving Diapers
SECTION 2: Child(ren) Information
SECTION 3: Random Photo or Video Consent
SECTION 4: Diaper Need Agreement and Signature
SECTION 5: Confirm Appointment Time
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. Select and Agree: Random photo or video Consent

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

4. Questions? Email BonifaceAndCelitaFoundation@gmx.com

DISTRUBUTION DAY / TIME ~ by Appointment ONLY ~
* Saturday's (at 1:00Pm)

We cannot guarantee all diaper need requests will be fulfill.

We DO NOT accommodate any requests without an appointment.
The Boniface and Celita Foundation provide emergency diapering supplies
for returning parents on a (Bi- Weekly) basis:

WHAT TO BRING WITH YOU WHEN PICKING UP DIAPERING SUPPLIES:

A) We require one form of identification for 'the parent'
OR the Authorized Adult who can pick up diapers for this Child' on behalf of the parent.
VALID IDENTIFICATION FOR THE PARENT: (current driver's license , state/government issue I.D or military I.D)

* Incomplete Application Will Not Be Accepted *

SECTION 1
PARENT/GUARDIAN RECEIVING DIAPER

Please Make Sure To:
Please complete each question. These questions are strictly based on your estimate and opinion, there is no right or wrong answers.
(Please answer each question as truthfully as you can).

Name of person completing this application:

Last NameFirst Name

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

Other

Parent Date Of Birth:

Date

Name of Parent needing diapering assistance:

First NameLast Name

Parent Race

Phone Number:

Area CodePhone Number

Phone Number listed above: "is my" ?

Other

Parent E-mail Address:

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 Address: (NO P.O Box):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you received diapering supplies from us in the past?

When was the last time you received diapering supplies from us?

What date?

How many children are you requesting diapering assistance for? We have: Sizes 2 thru 4 only " (NO pull-up's or Training pants currently)

Other

Did "the parent" experience any stress anytime in "the previous week(s) or last month" due to not having adequate diapering supplies for the child?

Would you like to explain?

Did "the parent" have to cut back on utilities in order to purchase diapers/diapering supplies for the child in the previous week(s) or last month?

Would you like to explain?

Do you need referrals for any other services?

Other

Services includes:

SECTION 2
CHILD(ren) INFORMATION

CHILD #1 INFORMATION

(Child #1) Name:

First NameLast Name

Child date of birth:

Date

Child's gender?

1. What Diaper Size (Child #1) was wearing “the last time" the parent received diapering supplies from the diaper bank?"

2. How does the parent plan on utilizing diapers for (Child #1)?

Example: daycare, childcare, for home

3. Did the parent "recently" had to withdraw this child from child/day care because they did not have adequate Diapers?

Other

If "Yes" please explain:

4. {As of today} Is the child enrolled in any Childcare, Daycare/ Early Head Start program(s)?

If "Yes" Please explain what program(s) the child enrolled in:

Address: Childcare, Daycare/ Early Head Start

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Child current grade level?

5. What Diaper size is 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?

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

Other

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

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

(Child #2) Name

First NameLast Name

Child date of birth:

Date

Child's gender?

1. What Diaper Size (Child #2) was wearing “the last time" the parent received diapering supplies from the diaper bank?"

2. How does the parent plan on utilizing diapers for (Child #2)?

Example: daycare, childcare

If "Yes" please explain:

3. {As of today} Is the child enrolled in any Childcare, Daycare/ Early Head Start program(s)?

If "Yes" Please explain what program(s):

Address: Childcare, Daycare/ Early Head Start

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

4. Diaper size is 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.

Other?

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

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

Other

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

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

SECTION 3
Random: Photo or Video Consent Release

Parent/Guardian consent to take photography and/or video

PLEASE READ
Boniface and Celita Foundation 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's benefited from our services.

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

We randomly will take photography and/or video of the parent and child(ren) so that our donors, supporters, and sponsors see that their donation is going directly to those that are in need.

There will be a limit to the number of each size give at each distribution.

Still Photographs: (photo's)

Please Select
YES - "I am Aware" |and| I FULLY UNDERSTAND

"I" the parent/guardian
"IS AWARE" that during distrubution of my diapering supplies the Boniface and Celita Foundation may randomly take photographs of the parent "myself" and my child(ren) which maybe will be viewed by the Boniface and Celita Foundation sponsor, partners, donors and funders.

"I'M AWARE" the Boniface and Celita Foundation may display still photo(s) on Boniface and Celita Foundation website, newsletter, or social media outlet(s).

" I'M AWARE " that photo(s) of myself and my child(ren) maybe taken randomly at distrubution and photographs may be used to promote the purposes of The Boniface And Celita Foundation with no compensation due to me

Other

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

Any issues you may have regarding BCF using photos of you and your child(ren) ?

Video:

Please Select
YES - "I am Aware" |and| I FULLY UNDERSTAND

"I" the parent/guardian
"IS AWARE" that during distrubution of my diapering supplies the Boniface and Celita Foundation may randomly take video of the parent "myself" and my child(ren) which maybe viewed by the Boniface and Celita Foundation sponsor, partners, donors and funders.

"I'M AWARE" the Boniface and Celita Foundation may display video on on Boniface and Celita Foundation website, newsletter, or social media outlet(s).

" I Am AWARE " that video of my myself and my child(ren) may be taken randomly at time of distribution and videos may be used to promote the purposes of The Boniface And Celita Foundation with no compensation due to me

Other

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

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

SECTION 4
CONFIRM YOUR APPOINTMENT

WHAT TO BRING WITH YOU WHEN PICKING UP DIAPERING SUPPLIES:

A) We require one form of identification for 'the parent' or the Authorized Adult who can pick up diapers for this Child' on behalf of the parent.
VALID IDENTIFICATION FOR THE PARENT: (current driver's license , state/government issue I.D or military I.D)

IF YOU CAN NOT MAKE YOUR APPOINTMENT:
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.

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

We require 24 hours advanced notice of need to reschedule/cancel an appointment, or families will be asked to wait one month for assistance.

DISTRUBUTION DAY / TIME ~ by Appointment ONLY ~
* Saturday's (1:00Pm)

We cannot guarantee all diaper need requests will be fulfill.

We DO NOT accommodate any requests without an appointment
The Boniface and Celita Foundation provide emergency diapering supplies
for returning parents on a (Bi- Weekly) basis only from our storing facility located on 155th street and West Dixie Highway, in North Miami Beach, Florida (33162).

The Boniface and Celita Foundation understands everyone experience financial hardship and we are here simply to help in those times of need.
The diaper program provides emergency diapering supplies - towards 'self suffiency'.

The number of diapers provided to parent is based donations the pantry receives from donors and sponsors.

Please note: Typically emergency diaper supply, sustain the child for a couple of days and in some cases for up to a week.

Other:

If you are unable to accommodate Saturday

SECTION 5
Diaper Need Agreement and Signature

1. Parent/Guardian agree to receive diapering/diapering supplies/clothing and or hygiene items in an ethical, conscientious manner. No products obtained from the Boniface And Celita Foundation- Diaper Bank may be sold, returned, exchanges, traded, bartered, used as gift, for fundraising, auctions or raffles. Items may only be used to provide personal services to the parent/guardian of the child.

You do fully comprehend everything you read in question 1?

2. Parent/Guardian “I” hereby indemnify, defend and hold harmless the Boniface And Celita Foundation- Diaper Bank, 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 Diaper Bank and then donated by The Diaper Bank.

“I” hereby forever release and discharge The Boniface And Celita Foundation- “Diaper Bank”, Center For Advancement Of Girls And Women, The Miami Diaper Bank, 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.

You do fully comprehend what you read in question 2?

3. Parent/Guardian acknowledges that Diaper Bank receives diapers donated by others; that Diaper Bank often receives donations of loose diapers or opened packages of diapers, clothing and children essentials; The Diaper Bank also purchase new diapers; and that Diaper Bank donates diapers, hygiene items with no consideration received. Although Diaper Bank believes, to its best knowledge, that donation of baby diapers, children items, from donors are safe, The Diaper Bank 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 BCF/Center For Advancement Of Girls And Women, to inspect the diapers, children essentials and hygiene items as receive.

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 Diaper Bank and The National Diaper Bank Network will not be shared or disclosed to any outside person/Organizations.

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

Thanks to our donors, supporters and sponsors generosity, their donations allows 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.

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 to parent/guardian voluntarily consent to random photography and/or video of the parent and their child(ren) is because:

IF YOU CAN NOT MAKE YOUR APPOINTMENT:

What is the Name of Person picking-up diapers/ing supplies **Must bring I.D**

First NameLast Name

What is the {Person picking-up diapering supplies} relationship with 'the parent' needing emergency diaper assistance ?

Other

What is the "Gender" of the that will be person 'picking-up diapering supplies' ?

If parent is UNDER 18 years old.

Name of person completing this application on behalf of the parent (if the parent is under 18 years of age)

First NameLast Name

"Initials" of Person completing this application:

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

Please Explain

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.

RETURNING PARENTS QUESTIONNAIRE