Child Information:

All information is used only by the JLL Diaper Bank in conjunction with the Junior League of Lawton for grant writing purposes and to better serve our clients. Your information will not be shared.

Please fill out a separate form for each additional child.

Child First Name

Child Last Name

Parent/Guardian First Name

Parent/Guardian Last Name

Child Date of Birth

Current Diaper Size

Child Gender

Female

Male

Phone

Child Lives With

Mother

Father

Grandparent

Foster Parent

Other Relative

Other

Child Race

Black/African American

Hispanic/Latino

White/Caucasian

Native Pacific/Other Native Island

American Indian

Other

Family Information

How many people live in the home?

How many adults (18+) live in the home?

How many children (5-17) live in the home?

How many children (under 5) live in the home?

Sources of Income

SSI

SNAP/Food Stamps

WIC

TANF

Subsidized Housing (Section 8)

Unsubsidized Housing (Affordable/Discounted)

Child Support

Other

None

Are you currently employed?

If yes...

Full-time

Part-time

Are any other adults in your household employed?

If yes,

Full-time

Part-time

What is your mode of transportation?

Personal Vehicle

Ride Share

Public Transportation

No Transportation

Parent Health Insurance

Private

SoonerCare/Medicaid

Uninsured

Child Health Insurance

Private

SoonerCare/Medicaid

Uninsured

I am currently picking up my diapers from:

Acceptance of Terms

JLL Diaper Bank makes no guarantees or warranties regarding the safety or quality of any items provided to recipient. JLL Diaper Bank receives donated items that have not been inspected for safety or quality. JLL Diaper Bank is providing items to the recipient at no cost. It is the responsibility of the recipient to inspect the items before use. JLL Diaper Bank expressly disclaims any responsibility or liability for any damages, loss, or injury/illness arising from services or products provided by our organization, sponsors, and donors and are not liable for any illness or injuries of any kind. By accepting items from JLL Diaper Bank, the recipient agrees to release the JLL Diaper Bank, its administrating agency, its officers, and volunteers from any liability and agree to hold them harmless against all liabilities, damages, losses, claims, causes of action, and suits of law or equity or obligation whatsoever arising out of or attributed to any actions from the distribution or the use of items provided by JLL Diaper Bank.

I accept

Cancel

Diaper Bank Client Application

Child Information:

Family Information

Acceptance of Terms