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Baby Booties Diaper Bank Partner Agency Application
Please fill out the information below to apply to be a Baby Booties Diaper Bank partner agency.
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* Indicates required question
Email
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Your email
Agency Name
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Your answer
Agency Address
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Your answer
Agency City
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Your answer
Agency Zip
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Your answer
Agency Website
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Your answer
Executive Director Name
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Your answer
Executive Director Phone Number and Extension
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Your answer
Executive Director Email
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Your answer
Your Agency is:
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501c3
Religion Organization
Government Organization
(Please note that after you complete your application you will be required to email Baby Booties Diaper Bank a copy of one of the following documents as proof of your agency status: 501c3 letter; Letter of good standing from denominational headquarters; Government letterhead.)
Describe agency mission/service provided to the community.
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Your answer
Source of Funding (check all that apply)
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Grants - Foundations
Grants - State
Grants - Federal
Corporate Donations
Individual Donations
Other:
Required
Description of Program Using Diapers
Program Name
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Your answer
Program Address (if different from Agency Address)
Your answer
Program Contact Person
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Your answer
Contact Person Email Address
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Your answer
Contact Person Phone Number and Extension
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Your answer
Program Description
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Your answer
Population Served
Ethnic composition of those served.
% Black/African American
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Your answer
% White/Caucasian
*
Your answer
% Hispanic/Latino
*
Your answer
% Asian
*
Your answer
% American Indian
*
Your answer
% Native Pacific/Other Native Island
*
Your answer
% Other
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Your answer
Zip Codes Served (please separate with a comma)
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Your answer
Do you measure the outcomes of your program?
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Yes
No
Please share any information you have on program outcomes.
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Your answer
How will the diapers be used by this program?
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Emergency supplies for families
Daycare
Homeless shelter
Domestic violence shelter
Outreach
Foster care
Option 7
Residential care onsite
Alcohol/drug recovery
Other:
Required
How does the agency program currently obtain diapers?
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Diaper drives
Purchase retail
Purchase wholesale
Do not currently obtain diapers
Do you receive diapers from other sources?
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Yes
No
Do you have a budget for diapers?
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Yes
No
Do you currently turn away clients due to a lack of diapers?
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Yes
No
Current Diaper Needs
Baby Booties Diaper Bank uses child-based distribution for providing diapers to partner agencies. This requires that the agency will ensure a Client Application form is completed on each child by the parent or guardian and kept on record at your agency. To estimate your organization’s diaper needs please complete the following table for your current clients. Upon approval of your application, we will review your needs including future projections to ensure we will be able to supply your agency.
Please complete the table below for the number of children your agency serves on a monthly basis. Write in the number of children for each diaper size needed – each child will receive a maximum number of diapers per child as set by Baby Booties Diaper Bank with your agency.
Newborn
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Your answer
Size 1
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Your answer
Size 2
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Your answer
Size 3
*
Your answer
Size 4
*
Your answer
Size 5
*
Your answer
Size 6
*
Your answer
Individuals Needing Period Products
Your answer
Distribution Alteration
The average quantity for distribution is 50 diapers per child. The standard for your agency will be set during Baby Booties Diaper Bank's agency approval process. If you need less than 50 diapers per child each month, please complete statement below.
Our Agency only requires the following number of diapers per child per month (optional)
Your answer
Agreement
Baby Booties Diaper Bank and the recipient agency agree that this agreement and any other agreements, records, or other documents utilized between the parties may be signed electronically in accordance with applicable law.
Signature
*
Your answer
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