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PDR Diapers + Cleaning Service Form
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Diapers + Cleaning Service
This form is for families who would like to utilize PDR's up-cycled diaper flats + diaper covers with PDR's once per week diaper service.
Caregiver Information
Please provide the information of child's caregiver in the section below.
First and last name
*
First and last name
Your answer
First and last name of second parent/ caregiver
Your answer
Relationship to child/ren needing diapers
*
Biological parent
Legal guardian
Grandparent
Other:
Required
Ethnicity of Parent/ Caregiver 1
*
Caucasian
Latino or Hispanic
Black/ African American
Asian
Native American
Native Hawaiian or Pacific Islander
Prefer not to say
Other:
Required
Contact Information
Who will we contact, and where will we be delivering diapers?
Name
*
Your answer
Email
*
Your answer
Phone number
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Information Involving Diaper Service
Please note the following:
There is a one-time $80 sign-up fee, per child.
Your monthly fee of $40 is based on household. You will not be charged more than $40 per month for diaper cleaning fees.
How many children in your family are in need of service?
*
1
2
3
4
5
Other:
When would you like to start diaper service? If child is not yet born, please indicate due date.
*
ASAP
Within the next couple of weeks
Within one month
Other:
Would you like to be charged weekly, monthly, or annually for diaper service? Your diaper service payment will be charged automatically after the first payment has been completed.
*
Weekly
Monthly
Annually
Would you like to contribute a monetary donation to PDR's Diaper Relief program in addition to your diaper service fee?
*
Yes!
No, thank you. I will make my contributions separately.
If you answered yes to adding a monetary contribution to your diaper service fee, please indicate how much you would like to contribute below (note: this amount will be taken out of every automatic payment)
$5
$10
$15
$20
$30
$40
$50
Other:
Clear selection
Additional Information
Are you interested in career opportunities at PDR?
Yes
No
Clear selection
Are you interested in volunteer opportunities at PDR?
Yes
No
Maybe
Clear selection
How did you hear about PDR's program?
Booth/ Educational Event
Google Search
Google Ads
Friend / Family Referral
Organization Referral
Social Media
Other:
Clear selection
Please name the organization/person you were referred by (if applicable).
Your answer
Send me a copy of my responses.
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