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Diaper Assistance Request Form

The Overtown Youth Center (OYC) partners with the Miami Diaper Bank to distribute diapers and baby wipes to families in need within Miami Dade County. Requests are limited to two times per year per child. If you are making a request for multiple children, please complete one form for each child that diapers are being request for.

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1. Parent/Guardian First Name: (Required)

2. Parent/Guardian Last Name: (Required)

3. I already received by Diaper Order: (Required)

Yes
No

4. Parent/Guardian Zip Code: (Required)

5. Parent/Guardian Phone Number: (Required)

6. Number of Adults Living in the Home: (Required)

7. How Many Children (ages 5-17) Live In The Home? (Required)

8. How Many Children (under 5) Live In The Home? (Required)

9. Sources of Income/Public Assistance: (Required)

  SSI
  SNAP/Food Stamps
  TANF
  WIC
  Housing/subsidized
  Housing/unsubsidized
  Child care assistance/subsidized
  Free/reduced lunch
  N/A

10. Is the Parent/Guardian Employed? (Required)

Yes
No

11. Parent/Guardian is Employed Full-Time or Part-Time? (Required)

  Full-Time
  Part-Time
  N/A

12. Did the Parent/Guardian lose their job during the pandemic? (Required)

Yes
No

13. If the Parent/Guardian lost their job during the pandemic, were they able to get a new job? (Required)

  Yes
  No
  N/A

14. Parent/Guardian's Monthly Income: (Required)

15. Parent/Guardian's Health Insurance Status: (Required)

  Private Insurance
  Medicaid
  Uninsured

16. Is this request being made for a Military Family? (Required)

Yes
No

17. Child First Name: (Required)

18. Child Last Name: (Required)

19. Diaper Size Requested for Child: (Required)

  Newborn
  Preemie
  Size 1
  Size 2
  Size 3
  Size 4
  Size 5
  Size 6
  Pull-Ups 2T-3T
  Pull-Ups 3T-4T
  Pull-Ups 4T-5T

20. Child Gender: (Required)

Male
Female

21. Child Date of Birth: (Required)

22. Child Lives With: (Required)

  Mother
  Father
  Grandparent
  Foster parent
  Other parent/relative

23. Child's Race/Ethnicity: (Required)

  Black/African American
  White/Caucasian
  Hispanic
  Asian
  American Indian
  Pacific Islander
  Multi-Racial
  Other

24. Child's Health Insurance Status: (Required)

  Private Insurance
  Medicaid
  Uninsured

25. Does the child have a disability or developmental delay? (Required)

Yes
No

26. Has the child ever had a health issue related to dirty diapers? (Required)

Yes
No

27. How many days per month does the child attend an early learning program or child care center? (Required)

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