Arizona Diaper Bank - Client Intake Form

Type of Identification Required

Please upload clear photos of the required documents

Upload Photo ID: *

Click to take photo or upload ID

Child's Birth Certificate or Proof of Guardianship:

Click to take photos or upload documents

You can select multiple files

Driver's License, State ID, or Passport Number: *

Benefit Information

AHCCCS, SNAP/EBT, WIC, Medicare, or Food Bank Card #:

Upload Benefit Proof:

Take photos or upload benefit cards/screenshots

You can select multiple files

Additional Information

Please provide accurate household and employment information

Are you Employed?

Yes No

Do you receive social security assistance?

Yes No

Gender of Head of Household:

Active Military:

Homeless:

Disabled:

Total Number of Family Members in Household: *

Any Disabled Adults/Children:

Expecting Children?

Yes No

Select Products Needed

Select all that apply

Children's Diapers

Period Products

Adult Incontinence Supplies

Are you picking up for someone else (Authorized Representative)?

Yes No

Children Information

Add information for each child who needs products (4 years old or younger)

How many children need products? * Children must be 4 years old or younger to receive products

Children's Diapers & Supplies

Diaper sizes are automatically selected based on children's information above

Note: Diaper selections are based on what you chose for each child above. You can select Baby Wipes and Diaper Inserts below.

Period Products

Select the products you need (limit applies)

Pads Tampons Period Kit Period Kit (Pads Only)

Adult Incontinence Supplies

Select size and check any additional supplies needed

Adult Pull-Ups

Size needed:

Adult Tabs

Size needed:

Other Supplies

Bladder Pads Men's Guards Bed Pads Adult Wipes

Authorized Representative Information

Information for the person authorized to pick up items

First Name: *

Last Name: *

Driver's License, State ID, or Passport Number: *

Client Agreement

Please read and agree to the terms below

Terms and Conditions

By checking the box below, I acknowledge and agree that:

All information I have provided in this intake form is accurate and truthful to the best of my knowledge.
I understand that providing false or misleading information may result in the immediate and indefinite discontinuation of distribution services.
I agree to notify Arizona Diaper Bank immediately if any of my information changes.
I understand that services are subject to monthly limits and availability of products.
I acknowledge that I am authorized to receive these products on behalf of the individuals listed in this application.
I agree to use the products provided for their intended purpose only.

I agree to the terms and conditions above and attest that all information provided is accurate. *

Today's Date: *

Please agree to the terms above to enable submission

CLIENT INFORMATION INTAKE FORM

Client Personal Information

Address Information

Emergency Contact

Type of Identification Required

Benefit Information

Additional Information

Select Products Needed

Children Information

Children's Diapers & Supplies

Diaper Sizes Selected

Baby Supplies

Period Products

Adult Incontinence Supplies

Adult Pull-Ups

Adult Tabs

Other Supplies

Authorized Representative Information

Client Agreement

Terms and Conditions