Every Bottom Covered & BMHA Diaper Distribution Registration Form
Please complete this registration form to enroll in the diaper distribution program at your BMHA housing complex. YOU MUST LIVE IN ONE OF THE BELOW COMPLEXES TO PARTICIPATE IN THIS PROGRAM. Children can receive supplies up until their 3rd birthday.  
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Email *
First Name *
Last Name *
Street Address *
City, State, Zip *
Phone Number
PLEASE PROVIDE A NUMBER TO REACH YOU AT FOR DROP OFFS
 *
Do you already receive diapers from Every Bottom Covered? *
If you do receive diapers from Every Bottom Covered, you can choose to pick them up through BMHA.  You CANNOT pick up twice in a month from both locations.
What Housing Complex Do You Live In?
YOU MUST BE LIVING IN ONE OF THESE COMPLEXES
 *
Child's Name *
Child's DOB *
Diaper Size *
Child's Name
Child's DOB
Diaper Size
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A copy of your responses will be emailed to the address you provided.
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