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Two Months Free Service Registration
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Email
*
Your email
Caregiver Information
Please provide the information of child's caregiver in the section below.
First and last name
*
First and last name
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
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:
Household income
*
less than $25,000
$25,000-$50,000
$50,000-100,000
$100,000-200,000
Prefer not to say
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/ State/ Zip
*
Your answer
Information Involving Diaper Service
How many children are in need of PDR's Diaper Service?
*
1
2
3
4
5
Other:
Please give the age and/or weight of each child you are registering:
*
Your answer
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
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