Bear Fire Diaper Form

About

14% of survey complete.

The answers provided on this form are for grant purposes and to determine the volume of diapers needed for ongoing Bear Fire Support. It will not factor into your eligibility to receive diapers. Butte Diaper Bank provides 50 diapers per child/adult and/or 25 Pull-Up's per child.

You will need to fill out an application in its entirety each time you experience diaper need. The form must be fully completed, meaning each question must be completely answered such as full name, child's full name, dates of birth, etc. in order for your request to be processed. Fraudulent applications will result in termination of eligibility for our services, as will resale of any distributed diapers or diapering supplies.

You may call (530)592-0882 for each monthly distribution date and time. You can also find this information on our Facebook page. Location, date, and time is subject to change due to weather conditions or volunteers schedules. We are currently attempting to maintain distributions on the last Saturday of each month from 9 am - 11 am.

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* 1. All of the information I am providing on this application is true and correct to the best of my knowledge. I understand that Butte Diaper Bank reserves the right to verify this information and if determined to be fraudulent myself and/or child(ren) will no longer be eligible to receive diapers or diapering supplies.

I understand and agree.

I do not agree, and I understand that by not agreeing I am voiding my application

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* 2. Please enter today's date

Date

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* 3. Contact Information

Full Legal Name (First name, Last name)

City/Town

ZIP/Postal Code

Email Address

Phone Number

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* 4. We will text message you with the date and time of Diaper Distribution. If text does not work for you, please select alternative way for us to contact you:

Other (please specify)

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* 5. How did you hear about Fontaine Foundation Diaper Bank?

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* 6. Si solo habla español:

Necesita un traductor - Por favor comuníquese con Butte 2-1-1 para obtener ayuda para completar esta solicitud

Tengo a alguien que pueda traducir por mí

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* 7. What source(s) of income does your household receive? Please check all that apply.

Full time work

Part time work

Child support

Unemployment

Alimony

TANF

WIC

SNAP (Food Stamps)

Housing (Section 8)

SSI

SSDI

Other (please specify)

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* 8. Household Income Range (Collected for demographic purposes only and will not disqualify you from receiving diapers)

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* 9. How would you describe your level of diaper need?

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* 10. What additional diapering supplies are needed? (Please note - these items are subject to availability)

Wipes

Rash Cream

Adult Bed Pads (only for those receiving adult briefs)

Other (please specify)

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* 2. Please enter today's date

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* 3. Contact Information

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* 4. We will text message you with the date and time of Diaper Distribution. If text does not work for you, please select alternative way for us to contact you:

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* 5. How did you hear about Fontaine Foundation Diaper Bank?

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* 6. Si solo habla español:

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* 7. What source(s) of income does your household receive? Please check all that apply.

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* 8. Household Income Range (Collected for demographic purposes only and will not disqualify you from receiving diapers)

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* 9. How would you describe your level of diaper need?

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* 10. What additional diapering supplies are needed? (Please note - these items are subject to availability)

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* 11. Who is the intended recipient of our services?