Diaper Pantry Form - Project BEE

Name *

First

Last

Email *

Date of Birth of Parent *

Last 4 of SSN

Phone *

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Citizenship *

(USA, CAN, other)

Tribal Affiliation *

(Affiliated Tribe name of parent or "N/A")

Military Affiliation *

(If yes, include dates of branch/dates of service)

Diaper Choice *

Have you ever applied for or received diapers from Dakota Diaper Pantry or another diaper charity? *

Yes
No

Where have you received diapers from? And what did you receive?

How many working adults are in the household at least part-time? *

Have you or someone in the household been restricted from working at least part time due to the COVID-19 pandemic? *

Yes
No

What is your highest level of education? Are you currently enrolled in higher education/training? If so, what program/where? *

Do you/your family currently receive any benefits such as WIC, SNAP, Medicaid, or TANF? *

How many people are in your family? *

How many individuals are you requesting diapers for? *

Do you currently own any cloth diapering supplies? * *

Yes
No

What diapers or diapering supplies do you own? *

Sizes Requested for Cloth *

Newborn
One size (8-35 lbs)
Trainers (toddler size)
Special needs youth

Sizes Requested for Disposable *

Indicate Trainers Size

If Other Indicate Sizes *

List Dependents Requesting Diapers For *

(Include Child's Name, Date of Birth/Due Date, Gender, Race, and Relationship to you)

Receiving diapers for my dependents will allow me to do the following (Check as many as applicable) *

If Other Please Describe:

The diapering supplies provided will be solely for use by my dependents. I will not sell or otherwise redistribute them. If I no longer have a need for them I will return them to Project BEE. (Contact Project BEE for return information) *

I Agree

I certify that the answers I have given to application questions are a complete and accurate representation of the truth. Any findings of misrepresentation or undisclosed relevant information will result in automatic denial of application *

I Agree

The diapering supplies provided will be solely for use by my dependents. I will not sell or otherwise redistribute them. When I no longer have a need for them I will return them to Dakota Diaper Pantry. *

I Agree

Contact Dakota Diaper Pantry for return information when you are ready to give diapers back.

Dakota Diaper Pantry is providing diapers free of charge that are in good usable condition to the best of our knowledge. *

I Agree

Dakota Diaper Pantry will not be held liable for any problems that may arise as a result of using the cloth diapers provided.

Dakota Diaper Pantry will provide diapers based on need and NOT gender. You may receive pink diapers for a boy or blue diapers for a girl, etc. *

I Agree

I understand that program is Minot, ND based and to participate, I will have to be able to pick up items in Minot, ND. There is no shipping of products.

I Understand

How did you hear about us?

Please upload ID of parent applicant *

Click or drag files to this area to upload. You can upload up to 15 files.

All applicants must provide proof of identity. (Ex: driver's license or other photo ID. Photo is required.)

Please upload proof of parenting *

Click or drag files to this area to upload. You can upload up to 15 files.

All applicants must submit proof of parenting (birth certificate and or custody paperwork).

Please upload proof of need *

Click or drag files to this area to upload. You can upload up to 15 files.

Applicants must be one or more: Income restricted- If income is restricting you from getting diapers, and you qualify for any government assistance (Medicaid, SNAP, WIC, etc.), please submit proof of assistance. Furloughed- If you are affected by a government shutdown, Please upload your government ID or paperwork showing you are a government employee and are not getting paid due to the shut down. US Veteran or Active Duty in immediate Family- Show LES, DD214, or ID card. Fostering children- Show placement paperwork. Disaster victim- Must show proof from Red Cross. Refugee- Must show proof from USCIS.

Dakota Diaper Pantry E-Form

205 3rd Ave. SE
Minot, ND 58701

Dakota Diaper Pantry E-Form

205 3rd Ave. SE Minot, ND 58701

205 3rd Ave. SE
Minot, ND 58701