New Client

Diaper Bank Request Form

New Client

If you are requesting assistance for the first time, please fill out the appropriate NEW CLIENT request form below. If you have received assistance from the diaper bank before, please fill out the RETURNING CLIENT form.

First-time clients will need to provide this additional first-time paperwork after submitting form before CCO can process the request.

Para las familias de habla hispana, utilizamos Google Translate para comunicarnos con usted, después de enviar los formularios. Si tiene alguna pregunta, envíenos un correo electrónico a board@conejocommunityoutreach.com. Gracias.

New Client

* Indicates required field

Name *

First

Last

Email *

Best contact number to reach you at. *

Please do not request a specific brand unless your child has an allergy, and please note, certain brands may take a longer time to obtain.

Please tell us about yourself and your family, and identify your specific diaper size needs. If there are brand allergies, be sure to note them. Thank you. *

Are you a resident of Conejo Valley (or immediate surrounding areas?) *

From whom did you hear about Conejo Community Outreach. Please provide the name or group so we can say thank you. *

Please type in your full and legal name, acknowledging that the information you've provided in this form is true and accurate. You may be asked to provide ID upon pickup. *

Submit

Client Referred by Organization

* Indicates required field

Name *

First

Last

Email *

Name of organization that referred you *

Name of individual at this organization you've been working with *

Their email address if you have it *

Please do not request a specific brand unless your child has an allergy, and please note, certain brands may take a longer time to obtain.

Please tell us about yourself and your child(ren). Please be specific regarding the size of diapers you need and if there are any brand allergies we need to note. *

Please enter your full name here as your electronic signature. With this step you are verifying that the above information is true and accurate. *

Submit

Eligibility

Before we can process your order, we ask that your review our eligibility requirements below and email the requested documents to us for verification. If an alternative form of identification needs to be discussed, please email us.

In the email's subject line, please write: "FULL NAME - Diaper Bank Eligibility Documents" and send to:
ConejoCommunityOutreach@gmail.com. Upon receiving, we will confirm receipt of documents and begin processing your order.

CONFIDENTIALITY: Under no circumstances is this information intended to be shared with anyone. These will remain confidential and are only for verification purposes in order to process your order.