Apply for Kit | One Diaper Canada

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

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: *

Application Details

Number of Children Needing Diapers: *

First Child's Name (Optional)

First Child's Age in months (for Size) *

First Child's Weight in lbs (for Size) *

First Child's Gender (Optional)

Male

Female

Does your first child have any special needs or allergies? *

Yes

No

You indicated that your first child has special needs and/or allergies. Please provide a brief explanation. *

Second Child's Name (Optional)

Second Child's Age in months (for Size) *

Second Child's Weight in lbs (for Size) *

Second Child's Gender (Optional)

Male

Female

Does your second child have any special needs or allergies? *

Yes

No

You indicated that your second child has special needs and/or allergies. Please provide a brief explanation. *

Third Child's Name (Optional)

Third Child's Age in months (for Size) *

Third Child's Weight in lbs (for Size) *

Third Child's Gender (Optional)

Male

Female

Does your third child have any special needs or allergies? *

Yes

No

You indicated that your third child has special needs and/or allergies. Please provide a brief explanation. *

Fourth Child's Name (Optional)

Fourth Child's Age in months (for Size) *

Fourth Child's Weight in lbs (for Size) *

Fourth Child's Gender (Optional)

Male

Female

Does your fourth child have any special needs or allergies? *

Yes

No

You indicated that your fourth child has special needs and/or allergies. Please provide a brief explanation. *

Have you used cloth diapers before? *

Yes

No

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.

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APPLY FOR A KIT

Beneficiary Intake Application

Contact Information

Application Details

Financial Information

Release & Indemnity - Waiver Agreement