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Permanent Diaper Assistance
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* Indicates required question
Email
*
Your email
Caregiver Information
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
How many children do you have?
*
1
2
3
4
5
Other:
How many children do you have in the home?
*
1
2
3
4
5
Other:
Age of Parent/ Caregiver
*
Your answer
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
Ethnicity of Parent/ Caregiver 2
*
Caucasian
Latino or Hispanic
Asian
Native American
Native Hawaiian or Pacific Islander
Prefer not to say
Not applicable
Other:
Required
Highest Education Completed by Caregiver 1
*
Some high school
High school
Bachelor's Degree
Master's Degree
Ph.D. or higher
Trade school
Prefer not to say
Other:
Highest Education Completed by Caregiver 2
*
Some high school
High school
Bachelor's Degree
Master's Degree
Ph.D. or higher
Trade school
Prefer not to say
Not Applicable
Other:
Household income
*
less than $25,000
$25,000-$50,000
$50,000-100,000
$100,000-200,000
Prefer not to say
Employment of caregiver 1
*
Full-time
Part-time
Seeking opportunities
Employment of caregiver 2
*
Full-time
Part-time
Seeking opportunities
Not applicable
Contact Information
Who will we contact regarding the family's involvement with the PDR program?
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 Need
What brings you to PDR?
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