diaper-request | CMFCAA's myCareManager

Diaper Distribution Agreement

Capital City Diaper Bank - Recipient Usage Agreement

Parent / Recipient

First Name *

Last Name *

Children

How many children are in diapers? *

Child 1 First Name *

Child 1 Last Name *

Child 2 First Name *

Child 2 Last Name *

Child 3 First Name *

Child 3 Last Name *

Child 4 First Name *

Child 4 Last Name *

Child 5 First Name *

Child 5 Last Name *

Child 6 First Name *

Child 6 Last Name *

Diaper Size(s) Received (select at least one, or Diapers Not Received)

Training Pants Received

Choose "Not received" for any size the family did not receive.

2T-3T

3T-4T

4T-5T

5T-6T

Packages

Total number of packages of diapers/training pants received by family *

Note: diapers must be received in order to receive wipes. Limit of one package of wipes per household (a household with four or more children in diapers may receive two).

Wipes were given

Number of wipes packages *

Wipes Not Received

Feedback

How do you feel about the number of diapers or training pants you received? *

It was not enough

It was just right

It is too much

Receiving these diapers/training pants for my children allows me to (check all that apply, at least one or fill in Other):

Other (please explain)

Acceptance of Service Terms

1. I acknowledge that the Capital City Diaper Bank (CCDB) requires this distribution agency to collect data. I understand that the data gathered about me and my family will ONLY be used by the Diaper Bank for purposes directly related to diaper distribution. Personally identifiable information will never be shared with any outside agencies, individuals, or organizations.

2. I will use these diapers ONLY for the child(ren) listed on this agreement and I will not sell, trade, or give away these diapers.

3. I may receive diapers provided by the Capital City Diaper Bank from only ONE of its partner agencies each month. I may not receive CCDB diapers from more than one of the following in the same month: Baby Grace, Beni Births LLC, Central Missouri Foster Care and Adoption Association, Common Ground, Community Health Center of Central Missouri, Jefferson City Parents as Teachers, Little Explorers Discovery Center, Pregnancy Help Center of Central Missouri, Rape and Abuse Crisis Service (RACS), South Callaway Parents as Teachers, or SSM Pediatric Clinic.

4. I understand that violating these policies and/or providing false information may result in termination from the diaper distribution program of the Diaper Bank.

I have read and accept the Acceptance of Service Terms *

Recipient Signature (type your full name) *

Draw your signature below with your finger or mouse *

Submit