APPLY FOR A KIT

Beneficiary Intake Application

Please completely fill out 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.

You can also download and print out the Beneficiary Intake Application PDF to submit by e-mail, fax, or mail.

You will also need to print out and sign the One Diaper Canada Beneficiary Waiver Form, to be uploaded with your application or sent to us via e-mail in order to process your application.

Beneficiary Intake Application

Contact Information

Application Details

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.

Agreement

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

I have read and agree to the Terms and Conditions and Release and Indemnity to: One Diaper Canada 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 ____________________________________________ name of child or infant under the age of four (4) years, 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. IN WITNESS WHEREOF we have set our hands and seals, this ________ day of ______________, 2015. Signed, sealed and delivered. __________________________________________ ________________________________ __________________________________________ signature of witness signatures of parent(s)/legal guardians