Diaper Request Form Please give us a little bit of information about yourself so we can serve you better. "*" indicates required fields Date MM slash DD slash YYYY Zip Code* Are you interested in learning more about cloth diapers?*YesNoGender of the Diaper/Brief User*MaleFemaleAge of the Diaper/Brief User*0-17 years18-59 years60+ yearsRace of Diaper/Brief User*American IndianAsianBlackPacific IslanderWhiteAmerican Indian & WhiteAsian & WhiteBlack & WhiteAmerican Indian & BlackOther/Multi-RacialEthnicity of Diaper/Brief User*HispanicNot HispanicHead of Household*MaleFemaleDoes the Diaper/Brief User have a place to live?*YesNoIs the Diaper/Brief User disabled?*YesNoHow many in your household? (Enter numbers only)*Annual Income*Below $10,000$10,000-$20,000$20,000-$30,000$30,000-$40,000$40,000-$50,000Over $50,000Where are you filling this out?* At Home At Work At the Diaper Bank At a Partner Agency Please describe where you filled out this formCAPTCHA