APPLY FOR A KIT

Beneficiary Intake Application

Please fill in ALL the information requested below. This information assists us in determining how we can best support you as well as how to put together a cloth diapering package that best suits your needs. All information that you provide is kept strictly confidential.

Note that the address that you provide will be the one we use to ship your kit – please ensure that it is COMPLETE (including your apartment number if it applies) and CORRECT.

Beneficiary Intake Application

If you are human, leave this field blank.

How will receiving a cloth diaper kit from One Diaper Canada be beneficial to your family?

Have you used cloth diapers before? *

Yes

Do you currently own any cloth diapers? If yes, what kinds (AIOs, pockets, covers and flat/prefold/fitted)?

Contact Information

Parent/Guardian First Name: *

Parent/Guardian Last Name: *

Street Number and Name *

City: *

Province: *

Postal Code: *

Daytime Phone Number: *

Evening Phone Number: *

Email Address: *

Financial Information

In order for us to meet the qualifications required for a charity as set out by CRA, we are required to collect household income information. Again, please know that information provided is kept strictly confidential and is used only for us to ensure we best meet your needs. No information provided will be given to any other organization, including the organization which may have referred you to One Diaper Canada.

Please provide your household income for the previous tax year:

Release & Indemnity - Waiver Agreement

I understand that the information that I have provided in this Intake Form will remain in strict confidentiality of One Diaper Canada and will not be shared with any outside agency or organization. *

Yes

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IN CONSIDERATION of the sum of $1 and the provision of a single diaper package by ONE DIAPER CANADA, we the undersigned, release and forever discharge ONE DIAPER CANADA, its officers, directors, employees, agents and volunteers and their heirs, legal representatives and assigns, from all actions, causes of action, damages, claims and demands whatever, which we, our heirs, legal representatives or assigns may have against ONE DIAPER CANADA by reason of the use of any diapers or other products or services provided to the undersigned by ONE DIAPER CANADA whereby any injury or damage may be sustained by our child as a result of an issue of such product or service.

AND FURTHER in consideration of the above sum, we agree to indemnity ONE DIAPER CANADA its officers, directors, employees, agents or volunteers and their heirs, legal representatives and assigns, against all actions, damages, claims and demands which may be brought against any of them by or on behalf of our child by reason of the use of any diapers, other products or services by such child both at present or in the future.

We have read over the above release and agreement to indemnify and understand the terms thereof and the responsibilities which we have assumed thereunder.

Terms & Conditions *

By checking this box you are stating that you have read and agree to the Terms and Conditions contained in the waiver agreement above.

Signature

Clear

We are a CRA registered charity!
Charity Registration Number: 806786398RR0001

Apply for Kit

APPLY FOR A KIT

Beneficiary Intake Application

Contact Information

Application Details

Financial Information

Release & Indemnity - Waiver Agreement