CNY Diaper Bank Cloth Diaper Kit Request Form

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Please complete the form below. Please note: we serve the Central New York region which includes the city of Syracuse and surrounding areas. If you are live out of the area or in another state, please try www.theclothoption.org.

Email *

First Name: *

Last Name: *

Zip code *

How many children do you need cloth diapers for? Please include their gender, age and weight. *

Are you able to pick -up your cloth diaper kit at our office in Liverpool, NY?

Yes

Clear selection

What is your level of experience with cloth diapers? *

I have never used them before.

I've tried them before but I use disposables only.

I've used cloth diapers in the past.

I am using cloth diapers now.

Do you have a washer and dryer at home? *

Yes

I hand wash.

I use the laundromat.

Number of working adults in household: *

More than 2

Required

Have you ever received CNY Diaper Bank diapers before? *

I have received cloth diapers

I have received disposable diapers

I have received both cloth and disposable diapers

I have never received diapers from the CNY Diaper bank before today

Receiving these cloth diapers for my child(ren) would allow me to (check all that apply): *

take child to daycare

look for work

go to work, school or job training

buy food

buy non-food necessities

spend more money on transportation (car payment, gas, vehicle repairs, bus pass, ride cost)

save money

pay down debt

reduce stress

help my child have less diaper rash

Other:

Required

How did you hear about our program? *

Facebook group

Doctor, Nurse, Doula, other healthcare worker

Google Search

Friend

Other:

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