Apply for Kit | One Diaper Canada

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:

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

I have signed and included (attached or will send via appropriate means) the One Diaper Canada Beneficiary Waiver Form. *

Yes

Please upload your signed copy of the One Diaper Canada Beneficiary Waiver Form. If you do not upload this form, you will need to email it to us directly.

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APPLY FOR A KIT

Beneficiary Intake Application

Contact Information

Application Details

Financial Information

Agreement

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