Delight & Co.Minot Area Diaper Pantry Application Name * First Name Last Name Email * Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number Country (###) ### #### Date of Birth of Parent * MM DD YYYY Last 4 of SSN What services are you interested in? * Disposable Diapers Wipes Formula Baby Clothes Baby Items Have you ever applied for or received diapers from Delight & Co Diaper Pantry or another diaper charity? * Yes No Citizenship * (USA, CAN, other) Tribal Affiliation (Affiliated Tribe Name of parent or "N/A") Do you/your family currently receive any benefits such as WIC, SNAP, Medicaid, or TANF? * List dependents requesting diapers for... * (include Child's Name, Date of Birth/Due Date, Gender, Race, & Relationship to you) How many working adults are in the household at least part-time? * Receiving diapers for my dependents will allow me to do the following... * (Check as many as applicable) Take a child to daycare Buy Food Go to Work Make my child happier & healthier Go to School / Job Training Pay Bills Other I understand that this 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 agree How did you hear about Delight & Co Diaper Pantry? Thank you for your diaper application to the Delight & Co Minot Area Diaper Pantry! We will reach out to you shortly.
