Lowell Diaper Bank - Agency Order Form
This form is for Lowell Diaper Bank member organizations only.

Current operations and diaper pick-up is currently twice a month on Thursdays 9:30 am - 12 pm. Contact us to confirm our days/hours: 978-905-8181,  Pandrews1223@gmail.com.  The location is at 167 Dutton St, Lowell
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Email *
The Lowell Diaper Bank is operated by Lowell Alliance, with support from Community Teamwork Inc. and individual and organizational donors.
Name and cell phone number of person picking up *
Name of Agency and Department *
If this is the first distribution day of the month - would you like to receive your total monthly allotment of diapers?
Clear selection
Check each size of diapers you are requesting (Sizes NB, 1, 2, 3, 4, 5, 6, and 7). 
Column 1
Newborn
Size 1
Size 2
Size 3
Size 4
Size 5
Size 6
Size 7
Please let us know how many families in Lowell you are providing diapers to for this request.  *
Date of your last request: M/D/Y. If this is your first request, select today's date and enter 0 for the remaining questions
MM
/
DD
/
YYYY
Total number of Lowell families who have received diapers since your last request *
Total number of 1-11 month old children who have received diapers since your last request *
Total number of 12-24 month old children who have received diapers since your last request *
Total number of 25-36 month old children who have received diapers since your last request: *
Total number of 37-48 month old children who have received diapers since your last request: *
Total number of 49-60 month old children who have received diapers since your last request: *
In what towns do your clients live? *
Required
How many clients from each of the above towns? (E.g. 3 from Dracut, 12 from Lowell, etc.) *
What is the race and ethnicity of your clients who have received diapers since your last request (please indicate number): *
0
1
1-5
5-10
More than 10
Latinx/Hispanic
African American
Native American Indian
African
Biracial
Southeast Asian - Cambodian
Southeast Asian - Other than Cambodian
White/Caucasian
Brazilian or Portuguese
Middle Eastern
Other
Any other comments or questions for our team?
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