Diaper Drive Registration Form Completing this form helps us plan and meet community need. This information will be sent to our Program Manager that will follow up with any support you need for your drive! Thank you for hosting a drive. Company/Organization Name* Contact Name* First Last Contact Title Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work PhoneCell PhoneEmail* Are you hosting a(n):* In person drive Virtual Drive Combination in person and virtual drive How many members does your company/group have?Please enter a number from 1 to 10000.Start Date* MM slash DD slash YYYY End Date* MM slash DD slash YYYY Please publish our drive on your website or social media! Yes No Would you like to challenge an organization, group or person? If so, who?Name of the organization we would like to challenge for this diaper drive (including contact information):How will the diapers get to the Diaper Bank?* We will arrange for delivery to your warehouse We will need someone to pick the diapers up We are hosting a virtual drive ONLY Drop-off/Pick-up Date MM slash DD slash YYYY Comments or QuestionsOur goal is to collect and/or raise money equivalent to: 0 – 500 diapers (less than 10 participants) 500 – 1,000 diapers (avg. 10-15 participants) 1,000 – 2,500 diapers (avg. 15-25 participants) 2,500 – 5,000 diapers (avg. 25-50 participants) 5,000+ plus diapers We would like Diaper Bank envelopes for financial donations. Yes We would like for the Diaper Bank to come to talk to our members. Yes No We would like information on sponsorship levels for your fundraiser, “Dancing With Our Stars” Yes EmailThis field is for validation purposes and should be left unchanged.
