Form

Diaper Bank Partner Agency Application 2022 - 23

League Year 2022-2023 (valid June 1, 2022 to May 31, 2023)

Please fill out the following application to be considered as a Partner Agency. Completion of the application does not guarantee acceptance.

The Junior League of Baton Rouge Diaper Bank proudly serves the parishes of East Baton Rouge, Ascension, Iberville, Livingston, West Baton Rouge, and West Feliciana.

Agency General Information

Agency Name:

Mailing Address:

City:

State:

Zip Code:

Website Address:

Please provide any Social Media Handles below.

Facebook:

Twitter:

Instagram:

Other:

Languages other than English: (Indicate spoken, written, or both.)

Please provide a PNG or JPEG good-quality image file of your agency’s logo to use for our flyers, signage, and social media via e-mail.

Executive Director's Name:

Executive Director's Phone (with extension):

Executive Director's Email:

Your Agency is a

501(c)3

Religious Organization

Government Organization (Includes Public Schools)

Please attach proof of your agency's Status 501(c)(3) Letter or Letter of Good Standing from Denominational Headquarters or Government Letterhead.

Please attach a copy of your agency's annual budget.

Agency Mission/Service Provided to the Community:

Describe the population you serve:

Ethnic composition of population you serve, including percentages, if available:

Geographic Regions Served (by parish and zip code):

Ages:

Partnership Engagement

Please explain how partnering with your agency will help to achieve the Junior League’s vision for “lasting community change in the areas of health, education, and cultural development."

If your agency is selected as partner agency, how do you plan to promote the JLBR Diaper Bank?

If your agency is selected as a partnering agency, how could you engage with the JLBR Diaper Bank? (Select all that apply.)

Participating in a service day at the Diaper Bank

Participating in JLBR’s media or advocacy efforts ( e.g., promoting National Diaper Need Awareness Week efforts)

Other

Description of Programs Using Diapers

Please describe your programs which will be using diapers. For your program 1, you will fill out the data in the fields below. If you have more than one program that will use diapers, you will also upload a document with a brief description of the service provided noting how the diapers will be used in the program. Provide the contact person with direct phone extension, cell phone, and e-mail address for each program.

Program 1 Name:

Program 1 Contact Person:

Program 1 Phone Number (with direct extension):

Program 1 Contact Cell Phone Number:

Program 1 Email Address:

Program 1 Description:

Do you measure outcomes for program 1?

Yes

You will be required to supply

Who your clients are

Zip codes where your clients live

Clients financial household range

Number of family members in the household

Whether the child needing diapers goes to daycare or not

Other

How will the diapers be used by program 1? (Check all that apply. Add additional ways in "Other" field.)

On-site residential program

Daycare

Emergency Assitance (on-site)

Emergency supplies for families (off-site)

Diapers are given out freely at community events

Diapers to be provided to another qualified agency

Diapers to be provided to another qualified agency (List agency names in "Other" field below.

Other

Does program 1 receive diapers from other sources?

Yes

Does program 1 have a budget for diapers?

Yes

Does this program currently turn away clients due to a lack of diapers? If yes, estimate the number in the "Other" field.

Yes

Other

Does this program have a dedicated diaper storage area?

Yes

Does this program serve walk-in requests for diapers from someone NOT enrolled in your program?

Yes

Additional Programs: Please upload a document to describe any additional programs which will be using diapers. Include a brief description of the service provided noting how the diapers will be used in the programs. Provide the contact person with direct phone extension, cell phone, and e-mail address for each program. Please follow the example set with Program 1.

Additional Programs Document Upload:

Which, if any, of these other supplies could your agency also use if they become available? (Select all that apply.)

Large diapers

Adult diapers

Swim diapers

Period products - Pads

Period products - Tampons

Estimate Your Distribution Needs

The data from this Distribution Estimation will be entered into the Junior League of Baton Rouge Diaper Bank database for each 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 need for diapers, please complete the following information based on 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.

The National Diaper Bank Network estimates diaper need at 50 diapers per month per child. For example, if you service 25 Newborns, diapers are supplied at 50 diapers per month. For your Newborns, you would receive 1,250 diapers.

Please complete the blanks below indicating the number of children your agency serves on a quarterly basis.

Newborn - up to 10 lbs.

Size 1 - up to 14 lbs.

Size 2 - 12 to 18 lbs.

Size 3 - 16 to 28 lbs.

Size 4 - 22 to 37 lbs.

Size 5 - over 27 lbs.

Size 6 - over 35 lbs.

Training Pants (2T/3T)

Training Pants (3T/4T)

Training Pants (4T/5T)

If you do not need 50 diapers per child each month, how many diapers per child per month do you need?

Diaper Distribution Day Pick-Up Contact Information

We have quarterly distributions which will be held on the following Friday's by appointment:

Distribution 1: Date coming soon
Distribution 2: Date coming soon
Distribution 3: Date coming soon
Distribution 4: Date coming soon

Please designate a person who will be responsible for picking up diapers on distribution day. This person needs to be accessible by cell phone on the day of distribution.

Designated Distribution Person

Name:

Email:

Cell phone:

Alternate Designated Person

Name:

Email:

Cell Phone:

Partner Agency Orientation Information

All selected agencies will be responsible for attending a mandatory Partner Agency Orientation Meeting prior to our first distribution. Orientation and distribution dates will be released upon acceptance as an agency. Orientation is held at the JLBR Diaper Bank which is located at 5355 Government Street, Baton Rouge, Louisiana 70806. This meeting will cover placing diaper orders for distribution, distributions, information that we need to be collected for grants and the National Diaper Bank Network, and give you other information about the JLBR Diaper Bank.

Executive Director Electronic Signature

By typing my name in the box below, I certify I am the Director of the Agency named in this application and that the information provided is correct.

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