Diaper

Request

Please complete and return to diaper@jlriverside.org

Date

Your Information

First Name Last Name

Zip code Email Address

Birth Date Mobile Phone

Are you a Annual Family Income

Are you employed
single parent?
Full Time
Yes Part Time
No Unemployed

Are you requesting diapers due to the COVID -19 Crisis?

Yes
No

If yes, please explain example: work shut down, reduced hours, furlough.
Please select ALL of the following that
apply: Select the assistance you are receiving
You are disabled Cash Assistance
You are a veteran Child Support
You are homeless Food Stamps
A family member is incarcerated Medical Assistance
You have are experiencing a crisis SSI / SSDI
not listed here Unemployment
WIC
None of the Above

What language(s) do you speak at home?

English Spanish
Other
Please tell us anything additional about your situation and why our assistance is important

Family Information
Please complete the information below for each diaper size requested

1. Child's Name (First and Last) Birth Date

Relationship to you Diaper Size

2. Child's Name (First and Last) Birth Date

Relationship to you Diaper Size

3. Child's Name (First and Last Birth Date

Relationship to you Diaper Size