PARTNER
AGENCY APPLICATION

*Please note that due to the high demand for diapers, we have a wait list of agencies and cannot activate all partner agencies as soon as applications are approved. We will keep all agencies on file and activate them into our diaper distribution program as soon as resources allow.

AGENCY FAQ

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Agency Information

Please fill out the information below to apply to be a Sweet Cheeks Diaper Bank partner agency.

User Name * (This is what you will use to log in to the agency portal once approved.)

User Email *

First Name *

Last Name *

Distributor Type * Agency Hospital

Address 1 *

Address 2

City *

State *

Zip *

Website *

Facebook Page

Twitter Name

Executive Director Name *

Executive Director Phone Number and Extension *

Executive Director Email Address *

Your Agency is: * 501(C)3 Religious Organization Government Organization

(Please note that after you complete your application you will be required to email Sweet Cheeks Diaper Bank a copy of one of the following documents as proof of your agency status: 501c3 letter; Letter of good standing from denominational headquarters; Government letterhead.)

Describe agency mission/service provided to the community *

Source of Funding * Check all that apply. Grants – Foundations Grants – State Grants – Federal Corporate donations Individual donations Other

Description of Program Using Diapers

Program Name *

Program Address 1 (if different from mailing address)

Program Address 2

City

State

Zip

Program Contact Person *

Phone Number with Direct Extension *

Mobile Number

Email Address *

Alternate Contact Person

Alternate Contact Phone

Alternate Contact Email

Program Description *

Population Served

Ethnic composition of those served

% Black/African American *

% White/Caucasian *

% Hispanic/Latino *

% Asian *

% American Indian *

% Native Pacific/Other Native Island *

% Other *

Zip Codes Served * Please separate zip codes with a comma

Poverty information of those served

% At Federal Poverty Level or below *

% 1-2 times above Federal Poverty Level *

% Greater than 2 times Federal Poverty Level *

% Unknown *

Ages *

Other

Do you measure outcomes for your program? * Yes No

Please share any information you have on program outcomes *

How will the diapers be used by this program? * Emergency supplies for families (off site) Outreach Foster Care Daycare On-site residential program Alcohol/Drug Recovery Domestic violence shelter Homeless shelter Other

Other, Please Specify

How does the agency program currently obtain diapers? * Purchase retail Purchase wholesale Diaper drives We don't currently obtain diapers

Do you receive diapers from other sources? * Yes No

Do you have a budget for diapers? * Yes No

Do you currently turn away clients due to a lack of diapers? * Yes No

Current Diaper Needs

Sweet Cheeks Diaper Bank uses child-based distribution for providing diapers to partner agencies. This requires that the agency will ensure a Client Application form is completed on each child by the parent or guardian. A copy of the signed form must be given to Sweet Cheeks Diaper Bank. The data from this application will be entered into the Sweet Cheeks Diaper Bank online agency portal database for each client serviced by your agency. All information will be kept in a secure manner and not released to any external organization other than in aggregate for grant writing and audit purposes. To estimate your organization’s diaper needs please complete the following table for your current clients. Upon approval of your application, we will review your needs including future projections to ensure we will be able to supply your agency.

Please complete the table below for the number of children your agency serves on a monthly basis. Write in the number of children for each diaper size needed – each child will receive a maximum number of diapers and/or pull-ups per child as set by Sweet Cheeks Diaper Bank with your agency.

Newborn *

Small * (Size 1)*

Medium * (Size 2)*

Medium * (Size 3)*

Large * (size 4) 22 to 37 lbs.*

Extra Large * (Size 5)*

Extra Large * (Size 6)*

Pull Ups * (2T/3T) 18 to 34 lbs*

Pull Ups * (3T/4T) 32 to 40 lbs*

Pull Ups * (4T/5T) 38+ lbs*

Distribution Alteration

The average quantity for distribution is 50 diapers or 30 pull ups per child. The standard for your agency will be set during Sweet Cheeks Diaper Bank's agency approval process. If you need less than 50 diapers or less than 30 pull ups per child each month, please complete statement below.

Our Agency only requires the following number of diapers per child per month (optional)

Our Agency only requires the following number of pull ups per child per month

Agreement

Sweet Cheeks Diaper Bank and the recipient agency agree that this agreement and any other agreements, records, or other documents utilized between the parties may be signed electronically in accordance with applicable law.

Signature *

By typing in your name and signing above, your agency agrees to the terms and conditions.

PARTNERAGENCY APPLICATION

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PARTNER
AGENCY APPLICATION