Rush County Indiana Diaper Bank Service Project Form December

INDIANA DIAPER BANK SERVICE PROJECT

In partnership with Indiana Diaper Bank and Indiana Diaper Bank Coalition Members
This form is for TANF, WIC, SNAP, and Hoosier Healthwise enrolled households. Applicants must upload proof of current and active eligibility during the pick-up time of diaper package.

All children enrolled in the above programs will receive 200 diapers (per child), which is a one-month supply of diapers every two months.

Up to 4 children can be included on this form. If there are additional children in the household that need diapers, please submit an additional form.

The person who fills out this form MUST be the one to pick up the diapers with identification.

Please do not contact the local WIC office with any questions. For any questions, please contact us via email at indianadiaperbankserviceproject@indianadiaperbank.org.

If you do not show up for your pickup slot after 2 times of signing up, Indiana Diaper Bank reserves the right to delete your submission.
OUTSIDE of WIC in Parking Lot, Rush Co., 509 Conrad Harcourt Way, Rushville, IN 46173 *
Name of caregiver with benefits (WIC, TANF, SNAP, Hoosier Healthwise) *

First NameLast Name
Current address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Phone Number*
Please enter a valid phone number.
Current Email *
example@example.com
Instructions for Finding Eligibility Documentation:

Clients can find and save proof of current eligibility for TANF, SNAP or an Indiana Health Coverage Program, from the Benefits Portal maintained by DFR at https://fssabenefits.in.gov/bp/#/. Upload photo/document of eligibility below.

Prospective clients with WIC benefits should have proof of eligibility on their WIC app for smart phone.

1. Log in to IN WIC App.

2. Click Benefits.

3. Take a screen shot of current benefits (Make sure that your current benefits dates include the date you will be picking up diapers)

4. Upload photo below.

Upload
Upload TANF, WIC, SNAP, and Hoosier Healthwise eligibility. This image must be identifiable and legible.*

Cancelof

Child 1 Start
Child #1:
Name of Child #1 requesting diapers*

First NameLast Name
Child #1 age*
Child #1 race/ethnicity*
Child #1: Select a diaper size
Supply Size :(200 diapers/2 months)*
Is there another Child in this household needing diapers?*

YesNo

Child 2 End

Child 3 End

Child 4 End
I certify that the information shown above is true and accurate to the best of my knowledge.*

I agree - Check this box and sign below if you are the applicantI agree - Check this box and sign below if you are filling out the form on behalf of the Applicant.
Signature*

Clear

Counter

	Size 1	Size 2	Size 3	Size 4	Size 5	Size 6
Amount

Size 1
Size 2
Size 3
Size 4
Size 5
Size 6
Should be Empty:

INDIANA DIAPER BANK SERVICE PROJECT

Child #1:

Child #1: Select a diaper size

Child #2:

Child #2: Select a diaper size

Child #3:

Child #3: Select a diaper size

Child #4:

Child #4: Select a diaper size