NewOrg Management Center

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.


Section 1.   Default Page
1.  Parent/Guardian First Name:
 
2.  Parent/Guardian Last Name:
 
3.  I already received by Diaper Order:
 
4.  Parent/Guardian Zip Code:
 
5.  Parent/Guardian Phone Number:
 
6.  Number of Adults Living in the Home:
 
7.  How Many Children (ages 5-17) Live In The Home?
 
8.  How Many Children (under 5) Live In The Home?
 
9.  Sources of Income/Public Assistance:
 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?
 
11.  Parent/Guardian is Employed Full-Time or Part-Time?
 Full-Time       Part-Time       N/A       
12.  Did the Parent/Guardian lose their job during the pandemic?
 
13.  If the Parent/Guardian lost their job during the pandemic, were they able to get a new job?
 Yes       No       N/A       
14.  Parent/Guardian's Monthly Income:
 
15.  Parent/Guardian's Health Insurance Status:
 Private Insurance       Medicaid       Uninsured       
16.  Is this request being made for a Military Family?
 
17.  Child First Name:
 
18.  Child Last Name:
 
19.  Diaper Size Requested for Child:
 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:
 Male       Female       
21.  Child Date of Birth:
 
22.  Child Lives With:
 Mother       Father       Grandparent       Foster parent       Other parent/relative       
23.  Child's Race/Ethnicity:
 Black/African American       White/Caucasian       Hispanic       Asian       American Indian       Pacific Islander       Multi-Racial       Other       
24.  Child's Health Insurance Status:
 Private Insurance       Medicaid       Uninsured       
25.  Does the child have a disability or developmental delay?
 
26.  Has the child ever had a health issue related to dirty diapers?
 
27.  How many days per month does the child attend an early learning program or child care center?