* 1. Please provide your contact information:

* 2. Are you now or have you ever had to choose between buying diapers and any of the following:

* 3. Have you ever had to re-use a dirty disposable diaper because you couldn't afford to buy enough diapers?

* 4. Have you considered using cloth diapers to cut down on your diapering expenses?

* 5. Do you have access to a washer / dryer?

* 6. Are you currently in school and/or working?

* 7. If you had easier access to diapers, would you be in school and/or working?

* 8. Are you currently using childcare?

* 9. Are you currently using any of the following programs:

* 10. How are you currently paying for diapers?

* 11. Why is your family experiencing diaper need?

* 12. How many children do you have? What are their ages?

* 13. Why would access to diapers (cloth or disposable) help you?

* 14. Is there anything else we should know about your story?

* 15. We would like to use your story (without disclosing your full name or address) to provide public exposure to the issue of diaper need. May we have permission to share your story and photo with appropriate members of Congress, the press, and to the public through http://www.jenniferlabit.com?

* 16. We'd like to have a photo of you and your children to attach to your story. Please email your photo to jenn@cottonbabies.com with the subject "Diaper Need: <your name>". Did you email the photo?

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