Indiana Diaper Bank Partner Agency Application Form
Partner Agency Annual Aplication
Please fill out the information below to apply to be an Indiana Diaper Bank partner agency.
Organization/ Agency Information
Legal Name of Organization/ Agency
*
Other Name Used by the Organization/ Agency
Your Organization/ Agency is:
*
501 (C)(3)
Religious Organization
Government Organization
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
EIN
*
Federal tax identification number
Organization/ Agency Main Phone
*
Please enter a valid phone number.
Organization/ Agency Website
*
Social Media Handle(s), if none please write n/a
*
*List all that apply including separate diaper program pages*
Partner Agency Contact Information
Name of Primary Program Contact Person
*
First Name
Last Name
Email
*
example@example.com
Phone (Ext)
*
Please enter a valid phone number.
Mobile
*
Please enter a valid phone number.
Name of Agency Executive Director
*
First Name
Last Name
Email
*
example@example.com
Phone (Ext)
*
Please enter a valid phone number.
Mobile
*
Please enter a valid phone number.
Diaper Program Description/ Status
Program Name Using Diapers/ Baby Essentials
*
Organization/ Agency Mission & Service Provided to the Community
*
Brief Program Description
*
*This statement will be used to provide referrals for services and will be placed on our website*
Has there been any change in your non-profit status (as defined by the IRS), your corporate status, your organization's name, or your mission/ vision?
*
YES- Please attach supporting documentation
NO
Supporting Documentation
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Source of Funding ( Check all that apply)
*
Grants- Foundations
Grants- Government
Donations
Sponsorship
Other
Organization/ Agency Annual Revenue
*
Client Diaper Use
If you are an applicant that currently does not have a diaper distribution, please fill out the following fields to the best of your ability.
Do you currently provide diapers to your clients?
*
YES
NO
If yes, how often does your organization/ agency distribute diapers to clients (If applicable)
Weekly
Monthly
Emergency Only
Other
How often does your organization/ agency currently obtain diapers ( Check all that apply)
*
Purchase Retail
Purchase Wholesale
Diaper Drives
Infrequent Donations
Other Agencies or Diaper Banks
We Don't
Do you currently turn away clients due to a lack of diapers?
*
YES
NO
Does your agency budget for purchasing diapers/ baby essentials?
*
YES
NO
How will the diapers be distributed? (Check all that apply)
*
On-Site Residential Program
Outreach
Emergency Supplies for Families
Day Care
Foster care
Alcohol/ Drug Recovery Domestic Violence
Other (Please Explain)
If you chose "other" please explain
How do you measure outcomes for your programs?
*
Please share how your program helps move families to self-sufficiency. Is there a success story you can share how diapers helped a family in need?
*
(Optional) Is there anything else you would like to tell us about your organization/ agency or your diaper program?
Partner Agency Population Served/ Demographics Information
If new partner agency applicant, please fill out to the best of your ability.
% of Diaper Recipients by Poverty Level
Please fill out the percentage below
Federal Poverty Level or Below
*
Ex: 90%
1-2 Times Above
*
Ex: 5%
>2 Times
*
Ex: 5%
% of Total Diaper Recipients by Age
Please fill out the percentage below
0-1 Years Old
*
Ex: 50%
2 Years Old
*
Ex: 25%
3-5 Years Old
*
Ex: 20%
6+ Years Old
*
Ex: 5%
% of Total Diaper Recipients by Race/ Ethnicity
Please fill out the percentage below
White/ Non-Hispanic
*
Black/ African American
*
Hispanic/ Latino Origin
*
Asian
*
Pacific Islander
*
Other
*
Partner Agency Projected Monthly Diaper Supplies
Indiana Diaper Bank uses child-based distribution for estimating a partner agency's diaper needs. Please complete the following table by indicating the number of children your agency serves or projects to serve on a monthly basis. During the application process, we will review these needs to ensure we will be able to supply your agency and assign you the appropriate Partnership Tier Level.
Put in the number of children for each diaper size needed.
*
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Distribution Alteration
The National Diaper Bank Network recommends the best practice for disposable diaper distribution is 50 diapers or 30 pull ups per child. The standard for your agency will be set during Indiana Diaper Bank's Partner Agency approval process. If you need to alter your Partner Tier level based on an increase or decrease of children served, please contact ______ directly.
Applicant Signature
*
Date
*
-
Month
-
Day
Year
Please Upload the Following Documents:
501(c)(3) Status
*
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Most Recent 990
*
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