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Temporary Diaper Assistance
If you need diapers and have been effected by the COVID-19 Pandemic, please fill out the following information. Once submitted, a staff member from the Austin Diaper Bank will contact you to setup an appointment.
* Indicates required question
First Name/Nombre de Pila
*
Your answer
Last Name/Apellido
*
Your answer
Date of Birth/Fecha de nacimiento
*
MM
/
DD
/
YYYY
Phone Number/Número de teléfono
*
Your answer
Email Address/Dirección de correo electrónico
*
Your answer
Street Address/Dirección de la calle
*
Your answer
City/Ciudad
*
Your answer
State/Estado
*
Your answer
Zip code/Código postal
*
Your answer
County of Residence/Condado
*
Choose
Travis County
Williamson County
Burnet County
Hays County
Bastrop County
Caldwell County
What is your preferred method of communication?/¿cuál es su método preferido de comunicación
*
Phone Call
Email
Ethnicity
*
White/Caucasian
Hispanic/Latino
Black or African American
Native American or American Indian
Asian or Pacific Islander
Other:
Have you lost income due to COVID-19/¿ha perdido ingresos debido a COVID-19
*
Yes
No
Are you enrolled in or receive assistance from any of the following agencies?
*
Del Valle CDC
Neighbor 2 Neighbor
Catholic Charities of Central Texas
Jeremiah Program
Avance
Refugee Services of Central Texas
Healthy Families, Travis County
Any Baby Can
Saint Louise House
None of the Above
Required
Household Information/Información del hogar
To receive diapers you must fill out the household information completely.
How Many Adults live in your household?/Cuántos adultos viven en su casa
*
1
2
3
4
5
How Many Children under 18 live in your household?/¿Cuántos niños menores de 18 años viven en su casa?
*
1
2
3
4
5
Other:
How many Children in your household wear diapers? /Cuántos niños usan pañales en su casa
*
1
2
3
4
5
Date of Birth for Child Wearing Diapers/Fecha de nacimiento del niño
*
MM
/
DD
/
YYYY
Date of Birth for Child Wearing Diapers (2)/Fecha de nacimiento del niño
MM
/
DD
/
YYYY
Date of Birth for Child Wearing Diapers (3)/Fecha de nacimiento del niño
MM
/
DD
/
YYYY
Income for Household (Yearly)/ingresos anuales para el hogar
*
$0 to $4,999
$5,000 to $9,999
$10,000 to $19,999
$20,000 to $29,999
$30,000+
Do you or does anyone in your family receive any of the following benefits? Check all that apply. / ¿Usted o alguien de su familia recibe alguno de los siguientes beneficios? Marque todo lo que corresponda.
*
SNAP (Food Stamps)
WIC
TANF
Children's Health Insurance Program (CHIP)
None of the Above
Required
Check off the assistance you are seeking. / Marque la asistencia que está buscando
*
Newborn Diapers
Diapers Size 1
Diapers Size 2
Diapers Size 3
Diapers Size 4
Diapers Size 5
Diapers Size 6
Pull Ups
Period Supplies
Adult Incontinence Supplies
Required
Thank you for completing this form. We will reach out shortly by phone or email to setup an appointment. / Gracias por completar este formulario. Nos pondremos en contacto en breve por teléfono o correo electrónico para concertar una cita.
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