2023 Diaper Assistance Form

Diaper Assistance Form
Parent or Guardian's Info

Please type your name as it appears on the ID you will be presenting at the time of pick up.
Mother or Female Guardian's Name *

First Name Last Name
Date of Birth*

MonthDayYear
Date
Father or Male Guardian's Name - NA if not applicable*

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number *
Format: (000) 000-0000.
Email *

Confirmation Emailexample@example.com
Zip Code *
County or Jurisdiction *
Have you received diapers from Women Giving Back before?*

YesNo
Did you receive diapers from Women Giving Back last month?*

YesNo
Receiving diapers for my child(ren) has helped my child:

Have less diaper rashesSleep betterCries lessTo be happiernone of the above
Receiving diapers for my child(ren) has helped me:

Change my child as often as I would likeFeel like a better parent/caregiverReduce my stress as a parentReduced my financial stressnone of the above
Household & Income Information

The Diaper Assistance Program is to help families that are income restricted. We are now requiring proof of eligibility.
Which proof of eleigibilty will you be providing at your initial intake appointment?*

Medicaid eligibility letter - currentTANF approval letterSNAP approval letterI do not have any of these
Because you do not have nay of the abouve documents please bring this form in completed and notarized. Self-Certification of Income
You can submit a photo of a current Medicaid/SNAP/TANF Eligibility Letter here (do not take photo of cards, we need to see the letter):
How many people are in your household?*
Annual gross income (2 Person Household)

$0 - $39,350$39,400 - $65,600$65,650 - $85,450$85,500+
Annual gross income (3 Person Household)

$0 - $44,250$44,300 - $73.800$73.800 -$96,150$96,200+
Annual gross income (4 Person Household)

$0 - $49,150$49,200 - $81,950$82,000 - 106,800$106,850+
Annual gross income (5 Person Household)

$0 - $53,100$53,150 - $88,550$88,600 - $115,350$115,400+
Annual gross income (6 Person Household)

$0 - $57,050$57,100 - $95,100$95,150 - $123,900$123,950+
Annual gross income (7 Person Household)

$0 - $60,950$61,000 - $101,650$101,700- $132,450$132,500+
Annual gross income (8 Person Household)

$0 - $64,900$64,950- $108,200$108,250 - $141,000$141,050+
How many children (17 years old & younger) do you have? *
Is the head of your household female?*

YesNo
Is anyone in your household 55 years of age or older?*

YesNo
Is any adult in your household unemployed? (Do not include children in school)*

YesNo
Is anyone in your household disabled?*

YesNo
Are you currently receiving WIC?*

YesNo
Are you currently receiving TANF?*

YesNo
Demographic Information
Ethnicity*

HispanicNon Hispanic
Head of Household Race*

American Indian or Alaska NativeAmerican Indian or Alaskan Native & Black or African AmericanAmerican Indian or Alaskan Native & WhiteAsianAsian & WhiteBlack or African AmericanBlack or African American & WhiteNative Hawaiian/Pacific IslanderWhite/CaucasianOther/Multiracial
Child(ren)'s Info

Please only provide info on children under 3 years old wear diapers. We do not provide pull-ups or night time diapers.
Photo of childs Birth Certificate/Birth Letter

If you would like to upload a photo of the birth certificate/birth letter you can do here, otherwise you will have to bring it to every pick up. Only Children under 3 years of age.
Child 1 - Name *

First NameLast Name
Child 1 - Date of Birth *

MonthDayYear
Date
Child 1 Birth Certificate - Only Provide info for children under 3
Your relationship to Child 1*

MotherFatherLegal Guardian
What sizes do you need for child 1?*

NewbornSize 4Size 1Size 5Size 2Size 6Size 3
Child 2 - Name

First NameLast Name
Child 2 - Date of Birth

MonthDayYear
Date
Child 2 Birth Certificate - Only Provide info for children under 3
Your relationship to Child 2

MotherFatherLegal Guardian
What sizes do you need for child 2?

NewbornSize 4Size 1Size 5Size 2Size 6Size 3
Child 3 - Name

First NameLast Name
Child 3 - Date of Birth

MonthDayYear
Date
Child 3 Birth Certificate - Only Provide info for children under 3
Your relationship to Child 3

MotherFatherLegal Guardian
What sizes do you need for child 3?

NewbornSize 4Size 1Size 5Size 2Size 6Size 3
Is there any other information or comments you would like to add?
Authorization & Release
Verified FY26

YesNo
- I certify that all information given in this form is true, complete, and accurate.
- I released this organization for any responsibility in case of accident, illness, or injury.
- I permit all information provided to the agency can be shared with WGB's partners in determining my household’s eligibility.
- I understand that all items provided by this program is intended for the members of my household.
- I understand that I must not sell or exchange any items I receive.
- I understand that what I receive is based on donations. Quantity and brands are based on inventory. Special requests can not be accomodated.
- I understand that the information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.
Select all that apply to your household.

Female Headed HouseholdHave a disabled person in the householdHave an elderly person (55+) in the householdHave an unemployed adult in the householdReceives TANFNone apply to my household
Name

First NameLast Name
Signature of Parent or Guardian*

Clear
Verified

YesNo
FY 25

Jan 24Feb 24March 24April 24May 24June 24July 24Aug 24
Income

Extremely LowVery LowLowModerate
FY 24

July 23Aug 23Sept 23Oct 23Nov 23Dec 23Jan 24Feb 24March 24April 24May 24June 24July 24Aug 24Sept 24Oct 24Nov 24Dec 24Jan 25Feb 25March 25April 25May 25June 25July 25Aug 25Sept 25Oct 25Nov 25Dec 25Jan 26Feb 26March 26April 26
Income reported
P/U Date

4/23/26
Month Served
#Babies
N
S1
S2
S3
S4
S5
S6
Should be Empty:

Diaper Assistance Form

Parent or Guardian's Info

Household & Income Information

Demographic Information

Child(ren)'s Info

Photo of childs Birth Certificate/Birth Letter

Authorization & Release