Diaper Depot Registration

Instructions: Please complete the form below to register for free diapers. Registration must be completed by 10am the day before diaper distribution.

I’m attending a diaper distribution at:(Required)

Parent/Guardian Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Last Four of Social Security Number(Required)

Date of Birth(Required)

Phone(Required)

Email(Required)

Marital Status(Required)

Is this your first time registering for diapers?(Required)

Please provide birth certificate or crib card for child(ren) you are registering for diapers.(Required)

Drop files here or

Max. file size: 128 MB.

Number of children under the age of 5 living in the home(Required)

Number of children ages 5-17 living in the home(Required)

Are you enrolled in Parents as Teachers?(Required)

Would you like to be contacted about FREE programs offered by the Erie Family Center?(Required)

Child(ren) Diaper Information

How many children need diapers?(Required)

Child 1 Name(Required)

Child 1 Birthday(Required)

Child 1 Gender(Required)

Child 1 Diaper Size(Required)

Child 2 Name(Required)

Child 2 Birthday(Required)

Child 2 Gender(Required)

Child 2 Diaper Size(Required)

Child 3 Name(Required)

Child 3 Birthday(Required)

Child 3 Gender(Required)

Child 3 Diaper Size(Required)

Child 4 Name(Required)

Child 4 Birthday(Required)

Child 4 Gender(Required)

Child 4 Diaper Size(Required)

Beginning January 1, 2024 all Diaper Depot participants will be required to show some form of ID at pickup. If someone other than the Parent/Guardian is picking up diapers on their behalf, enter their name below. The pick up person will be required to show some form of ID at pickup. Caseworkers will only be able to pick up for a Maximum of 2 clients

Comments

This field is for validation purposes and should be left unchanged.

Diaper Depot Registration

Child(ren) Diaper Information

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