Partner agencies ONLY please complete this form – Not for Individual REQUESTS

We currently have a good supply of most diapers and wipes. Please place orders-by the 8th of the month- to meet the needs of your clients and we will fulfill them as long as we can.
We are still working to ensure our distribution meets your needs
while keeping all safe and well in accordance with current COVID-19 best practices.

We just received a donation of size 7’s and have an abundant supply of wipes. Please add these to your order if your families can use them.

REMEMBER PICK-UP WILL NOW BE AT OUR NEW LOCATION AND ON THE THIRD MONDAY.
Thanks so much for all you do!

Name of Partner Agency Representative Submitting Order(required)

Email(required)

Please Select The Partner Agency You Represent

Phone Number(required)

Diaper orders available for pick-up on the THIRD (3rd) MONDAY between 10 a.m. and 12 p.m. at 1301 Blue Spruce..

Preemie - Enter number of packages requesting

Newborn - Enter number of packages requesting

Size 1 - Enter number of packages requesting

Size 2 - Enter number of packages requesting

Size 3 - Enter number of packages requesting

Size 4 - Enter number of packages requesting

Size 5 - Enter number of packages requesting

Size 6 - Enter number of packages requesting

Pull Ups 2T/3T - Pack of 6

Pull Ups 3T/4T - Pack of 6

Pull Ups 4T/5T - Pack of 6

Any comments, questions, or concerns about your order?

DATA SUBMISSION

Please Select Agency(required)

Email(required)

Name of Person Submitting Data(required)

Phone Number(required)

Number of Unique Individuals Served(required)

Number of Recipients Employed(required)

Number of Recipients Unemployed(required)

Ethnicity of Recipients - List each unique ethnicity and correlating number of recipients(required)

Zip Codes of Recipients(required)

Number of Disabled Persons Served(required)

Number of Veterans Served(required)

Number of Children Under 1 Year Served(required)

Number of Children Over 1 Year Served(required)

Number of Diaper Packs Distributed(required)

Number of Pull-Ups Distributed(required)

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Partner agencies ONLY please complete this form – Not for Individual REQUESTS

DATA SUBMISSION

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