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Diapers of Hope
If you would like free diapers, menstrual products or adult diapers, please complete this form. All responses are confidential and collected to better assist you. Thank you.
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Email
*
Your email
Name (First and Last)
*
Your answer
Phone number
*
Your answer
Address
*
Your answer
Please select the items that you need
*
Baby Diapers
Menstrual products
Adult diapers
Required
Number of kids in diapers (if applicable)
*
Choose
1
2
3
NOT APPLICABLE
Number of total kids in your household
*
Choose
1
2
3
4
5+
NOT APPLICABLE
Do you or your child have a disability?
*
Choose
Yes
No
Are you willing to accept used items?
Yes
No
Clear selection
Are you a single parent?
Yes
No
Clear selection
Do you consent to have you and your child photograph or videotaped for our website?
*
Yes
No
Check all that apply- answers are confidential. Is anyone in your family/household (this includes you):
*
Receiving government assistance
Have a child in foster care
Undocumented
Homeless/unhoused
US Veteran
Part of the LGTBQ+ community
Family member died due to Covid-19
Family member with a serious medical condition (for example diabetes, mental illness, cancer, etc.)
Required
What other needs do you have?
Your answer
How has the pandemic affected you or your family? What challenges do you face right now? Please be specific.
Your answer
Send me a copy of my responses.
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