New Diaper Registration - Erie Family Center

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REGISTER for FREE Diapers

Please complete the form below to register to receive free diapers.

I'm attending a diaper distribution at:*
I understand that I am only able to attend TWO diaper distributions per month at any locations. Abuse of diaper distributions will lead to inability to participate in the program.*
- I Agree
Guardian Name*
Guardian First Guardian Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Email
Number of children under 5 living in the home.*
Number of children ages 5-17 living in the home.*
Is the parent/guardian employed?*
- Yes - Both Parents
- Yes - One Parent
- No
Which sources of income apply to your family? (Please select all that apply)*
- SNAP/Food Stamps
- WIC
- SSI
- TANF
- Housing - Subsidized
- Housing - Unsubsidized
- None of the above
Are you a military family?*
- Yes
- No
Does every CHILD in your household have insurance?*
- Yes - Privately Carried
- Yes - Medicaid
- No
Does every ADULT in your household have insurance?*
- Yes - Privately Carried
- Yes - Medicaid
- No
Beginning in January, Erie Family Center will have classes via Zoom for 1-2-3 Magic, More Magic and Tantrums. 1-2-3 MAGIC And More 1-2-3 Magic addresses the difficult task of child discipline with humor, keen insight and proven experience. Tantrums addresses managing meltdowns in public and private.*
- Yes! Please contact me with information on these free classes
- No, thanks
Would you like to be contacted with information about our upcoming Incredible Years program? The Incredible Years is an evidence based program designed to strengthen parenting skills, prevent and treat behavior problems. The program specializes in children ages 5-15yrs but the tools learned can apply to all ages. These will be via Zoom and starting in the upcoming weeks. You do not need custody of your children to participate.*
- Yes! Please contact me with information!
- No, Thanks
Are you a 'Parents as Teachers' Family?*
- Yes
- No
Who is your Parent Educator?
Would you like to be contacted about Erie Family Center programs?*
- Yes
- No
Child(ren) Diaper Information
Child's Name*
First
DOB*
Date Format: MM slash DD slash YYYY
Please upload a picture of your child's birth certificate.
Drop files here or
Child's Gender*
- Female
- Male
- Prefer not to say
Race*
Who does the child live with?*
- Mother
- Father
- Both Parents
- Grandparents
- Foster Parents
Diaper Size Requested*
Add Another Child
- Add Another Child
Child's Name*
First
DOB*
Date Format: MM slash DD slash YYYY
Please upload a picture of your child's birth certificate.
Drop files here or
Child's Gender*
- Female
- Male
- Prefer not to say
Race*
Who does the child live with?*
- Mother
- Father
- Both Parents
- Grandparents
- Foster Parents
Diaper Size Requested*
Add Another Child
- Add Another Child
Child's Name*
First
DOB*
Date Format: MM slash DD slash YYYY
Please upload a picture of your child's birth certificate.
Drop files here or
Child's Gender*
- Female
- Male
- Prefer not to say
Race*
Who does the child live with?*
- Mother
- Father
- Both Parents
- Grandparents
- Foster Parents
Diaper Size Requested*
Add Another Child
- Add Another Child
Child's Name*
First
DOB*
Date Format: MM slash DD slash YYYY
Please upload a picture of your child's birth certificate.
Drop files here or
Child's Gender*
- Female
- Male
- Prefer not to say
Race*
Who does the child live with?*
- Mother
- Father
- Both Parents
- Grandparents
- Foster Parents
Diaper Size Requested*
I understand that any diapers received from the Diaper Depot program may not be sold. If I am found to be selling diapers obtained from the Diaper Depot, I will be unable to participate in future distributions.*
- I Agree
CAPTCHA
Beginning January 1, 2023 all Diaper Depot participants will be required to show some form of ID at pickup- every time. We will also be updating our records and will need some form of birth certificate/placement papers or crib card to be shown in January of every year. Please type your initials below to acknowledge this policy change.*
Beginning January 1, 2023 you must identify if someone is picking up diapers on your behalf at every distribution. Please list the name below of the person you will have picking up for you: (if applicable)

The Erie Family Center is the only Diaper distribution organization associated with a nationally accredited program within a 100-mile radius - National Diaper Bank Network.

Thank You to our Community Funding Sources

Location

606 Raspberry St.
Erie, PA 16502

Hours:
Mon-Fri 9AM-5PM

CONTACT

CALL: 814-520-8214

EMAIL US

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