Little Stars Application

Parent/Guardian Name

Phone

Email

Address

Proof of Address:

Proof of a ultility bill in the last 30 days with your name on it.

Child's Name

Child's Date of Birth

Month

Day

Year

Diaper Size Needed

How many people over the age of 18 live in your home?

How many children under the age of 18 live in your home?

Do you have income?

Yes

No

If no, how do you pay for necessities?

If yes, what is your source of income?

Please provide proof of income

Please provide proof of income (pay stub in the last 30 days, bank statements, government benefit letter, most recent tax return)

I understand that diaper support is limited and not guaranteed each month.

Yes

No

I agree to pick up diapers during scheduled distribution days or notify the program if I am unable to attend.

Yes

No

Please sign here implying that the information you provided is true and accurate.

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