PDR Diaper Cleaning Service Form

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E-mail *

Cleaning Service

This form is for families who already have reusable diapers and would like Permanent Diaper Relief to wash and dry them.

Caregiver Information

Please provide the information of child's caregiver in the section below.

First and last name *

First and last name

First and last name of second parent/ caregiver

Relationship to child/ren needing diapers *

Biological parent

Legal guardian

Grandparent

Egyéb:

Kötelező

Ethnicity of Parent/ Caregiver 1 *

Caucasian

Latino or Hispanic

Black/ African American

Asian

Native American

Native Hawaiian or Pacific Islander

Prefer not to say

Egyéb:

Kötelező

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, and where will we be delivering diapers?

Name *

Email *

Phone number *

Street Address *

City *

State *

Zip Code *

Information Involving Diaper Service

PDR's diaper service is on a sliding-scale fee model based on your income.

How many children in your family are in need of service? *

Egyéb:

When would you like to start diaper service? *

ASAP

Within the next couple of weeks

Within one month

Egyéb:

PDR requires every diaper service member to provide proof of income, proof of residency, and proof of child to qualify for our sliding-scale fee model ($10-20 per week, twice a week pick-up). If you would like to opt out of sending this information, and thus opt out of applying for our sliding scale fee, you can choose to do so here. *

Yes, I would like to opt out of the sliding-scale fee model. Please charge me $20 per week for service.

No, I would like to provide proof of income, residency, and child to take advantage of the sliding-scale fee model

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)

$10

$15

$20

$30

$40

$50

Egyéb:

Kijelölés törlése

Additional Information

Are you interested in career opportunities at PDR?

Yes

Kijelölés törlése

Are you interested in volunteer opportunities at PDR?

Yes

Maybe

Kijelölés törlése

How did you hear about PDR's program?

Booth/ Educational Event

Google Search

Google Ads

Friend / Family Referral

Organization Referral

Social Media

Egyéb:

Kijelölés törlése

Please name the organization/person you were referred by (if applicable).

Please email required documentation to admin@permanentdiaperrelief.org

Proof of residence, proof of income, proof of child.

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