All of the information I am providing on this application is true and correct to the best of my knowledge. I understand that AngelaCARES, Inc reserves the right to verify this information and if determined to be fraudulent myself and/or child(ren) will no *

I understand and agree

PLEASE READ BEFORE APPLYING

Diapers are only for Hudson County residents
Diapers are provided for children up to their third birthday and younger
The child must be born to receive diapers
YOU ONLY NEED TO FILL OUT THE FORM ONE TIME IF YOU FILL OUT MORE THAN ONE TIME YOUR APPLICATION WILL BE DENIED

Parent or Guardian's Info

Please type your name as it appears on the ID you will be presenting at the time of pick up.

Name *

First Name

Last Name

Contact Information

Phone *

Email *

Verify Email *

Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Parent Birthdate *

(mm/dd/yyyy)

Type of person? *

Parent/Guardian

Gender *

Ethnicity *

Have you received diapers from AngelaCARES, Inc before? *

Yes

No

Did you receive diapers from AngelaCARES, Inc last month? *

Yes

No

How did you first hear about AngelaCARES Diaper Distribution? *

A friend or family member told me

I saw you distributing diapers

I was referred by another organization

Internet Search

Social Media

Household Information

How many individuals live in the household? *

How many of these individuals are children (under 18)? *

What source(s) of income does your house receive? Please check all that apply. *

Full-time Work

Part-time Work

Child Support

Alimony

TANF

SNAP (Food Stamps)

Unemployment

Housing (Section 8)

None

Household Income Range (Collected for demographic purposes only and will not disqualify you from receiving diapers) *

How would you describe your level of diaper need? *

Do you have healthcare insurance? *

What is the name of your healthcare insurance provider? *

If other, please type below

Child(ren)'s Info

Please only provide info on children who are receiving diapers. We do not provide pull-ups or nighttime diapers. Please submit documentation for each child

First time applying? *

Yes

No

AngelaCARES Diaper Distribution requires documentation that children in need of diapers listed on this application are in the care if the adult listed on this application. You will need to provide documentation with you or your child's date of birth. Whic

Number of child(ren) you are registering for *

Child 1 Birthdate *

(mm/dd/yyyy)

Child 1 Size Diaper (Please put the correct size, if you do not put the correct size you will receive the size diapers on your application) *

File Upload *

Please upload Child 1 Birth Certificate/Discharge papers

Child 2 Birthdate

(mm/dd/yyyy)

Child 2 Size Diaper (Please put the correct size, if you do not put the correct size you will receive the size diapers on your application)

File Upload

Please upload Child 1 Birth Certificate/Discharge papers

Child 3 Birthdate

(mm/dd/yyyy)

Child 3 Size Diaper (Please put the correct size, if you do not put the correct size you will receive the size diapers on your application)

File Upload

Please upload Child 1 Birth Certificate/Discharge papers

If someone is picking up for you (Leave their name) If you are picking up please write Self *

Authorization & Release

I certify that all information given in this form is true, complete, and accurate.
I released this organization for any responsibility in case of accident, illness, or injury.

I understand that all items provided by this program are intended for the members of my household.

I understand that I must not sell or exchange any items I receive.

I understand that what I receive is based on donations. Quantity and brands are based on inventory. Special requests can not be accommodated.

I released this organization for any responsibility in case of accident, illness, or injury.

I permit all information provided to the agency can be shared with WGB's partners in determining my household’s eligibility.

I understand that the information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.

Diaper Pickup Information

We will email you confirmation the week of Diaper Pickup which will be the last week, if otherwise!

Please make sure to check your Spam/Junk folders.

Please do not contact us for your application number.

If you do not have your ID to pick up diapers, we cannot distribute diapers.

You can only pick up for yourself and only 1 family.

If you do not have the pickup persons information, you will not recieve their diapers.

Please bring your ID

Diaper Pickup

November 22nd, 2024 10am-12pm

AngelaCARES, Inc 512 Ocean Avenue Jersey City, NJ 07305

ACI Monthly Diaper Registration

PLEASE READ BEFORE APPLYING

Parent or Guardian's Info

Contact Information

Household Information

Child(ren)'s Info