Form

Diaper Bank Partner Agency Statistics Request Form 2021-22

Data Reported for the Month of

Year:

Agency Name:

Phone number:

Email:

Name of Specific Agency Program (if applicable):

Number of clients served:

Demographics of Clients Served

1. Ages:

2. Race(s):

3. Location(s) (Zip codes):

Number of diaper packs distributed (25 diapers in each pack):

As a result of receiving diapers from the JLBR Diaper Bank, our agency can:

If your agency received more diapers from the JLBR Diaper Bank, your agency could:

Impact Numbers (Any statistics / details about your program you would like to add):

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