Emergency Assistance - Potential Client

Emergency Assistance – Potential Client

This form captures information from a potential client requesting ilooklikeLOVE emergency diaper assistance.

"*" indicates required fields

Please check the requirement you meet for Emergency Diaper Assistance:*

***If you do not meet any of these requirements but still need inventory, you can participate in our Diaper Day events if you are WIC/SNAP eligible. Come out of this form and visit ilooklikelove.org/events for upcoming dates and locations.

SERVICE PROVIDER REFERRING YOU

Emergency diaper assistance is available by referral from a service provider only. You must be able to provide contact information and/or documentation so the service can be verified. IF YOU CANNOT PROVIDE A REFERRING AGENCY CONTACT, YOU WILL NOT BE APPROVED FOR EMERGENCY ASSISTANCE but you can still participate in our monthly Diaper Day events if you are WIC/SNAP eligible. Leave this form and visit ilooklikelove.org/events for upcoming dates and locations.

Are you currently receiving services from another program or organization?*

Yes

Name of Organization Referring You*

Name of Person at Organization Referring You*

Your Contact's Email Address*

Your Contact's Phone Number*

YOUR INFORMATION

Please provide the requested information.

Your Parental Status*

“I am the biological parent.”

“I am the the legal guardian.”

“I am the foster or adopted parent.”

“I have kinship foster care.”

Please indicate below the child’s relationship to you. EMERGENCY DIAPER ASSISTANCE IS ONLY AVAILABLE TO BIOLOGICAL, FOSTER, ADOPTED, PARENTS OR LEGAL GUARDIANS. Documentation of parental status (for example, copy of birth certificate, court papers, etc…) may be required.

Your Name*

Your Date of Birth*

Your Contact's Email Address*

Your Phone Number*

Your Address of Residence (including zip code)*

Please describe your crisis that prompted this request.*

CHILD INFORMATION

If assistance is approved, you may receive 100 diapers and other essentials per child for up to two children. Both diapers and pull-ups are available for approved emergency assistance cases only. Please provide the necessary information below to process each child’s donation.

Child Name*

Child Date of Birth*

Diaper Size for Child Receiving Diapers*

Select the diaper size needed for this child.

Child Name #2 (only if applicable)

Name of the 2nd child. Do not complete if there is only one child.

Child #2 Date of Birth (only if applicable)

Date of Birth for the 2nd child. Do not complete if there is only one child.

Diaper Size for Child #2 Receiving Diapers (only if applicable)

Select the diaper size needed for this child. Do not complete if there is only one child.

Document Upload

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 50 MB, Max. files: 4.

Please upload the following: *Valid Photo ID *A copy of your case management or social worker documentation from your referring organization *Any additional paperwork confirming parental or guardianship status of the child

CONFIRMATION

By entering your first and last name below, you certify that the information provided in form is accurate. You also approve for ilooklikeLOVE to contact your referring agency contact by email or by phone to verify the information provided or to get additional information.*

This field is for validation purposes and should be left unchanged.

Emergency Assistance – Potential Client