New London Youth Affairs

Diaper Bank Registration Form

Please complete as accurately as possible and fill out completely. This information is used for Diaper Bank info only, and your information is not shared. Thank you.

To curb spamming of our form, your IP address has been automatically recorded; 34.239.150.167.

Today's Date:
Parent/Legal Guardian Name:
Parent/Legal Guardian Date of Birth:

What is your relationship to the children for whom you are applying for diapers?

Name of Child 1:
Date of Birth:		male female
Size (s) of diapers and/or pull ups requested:

Name of Child 2:
Date of Birth:		male female
Size (s) of diapers and/or pull ups requested:

How many people are living in your household?

Please provide some information about the people living in your household:

Name:
Date of Birth:		male female

Name:
Date of Birth:		male female

Name:
Date of Birth:		male female

Name:
Date of Birth:		male female

Race:
Ethnicity - Is parent Hispanic:	yes no
Single Parent:	yes no

Your approximate combined monthly income is: $

Address:

City:
State:
Zip Code:

E-mail address:
Telephone number:

Is your household receiving any of the following?

Medicaid / Husky   Yes   No
TFA / Cash Assistance   Yes   No
Child Care Assistance (ex: School Readiness, Care 4 Kids)   Yes   No
SNAP   Yes   No
WIC   Yes   No
Housing or Rental Assistance   Yes   No
Other (not listed)   Yes   No