Cheyenne-Kiowa-Lincoln Early Childhood Council
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Diaper BAnk Pre-Registration
Date
Phone Number
Name
Email
Physical Address
City
State
ZIP
Mailing Address
City
State
ZIP
County
Select one...
Cheyenne
Lincoln
Number of Children in Diapers
Sizes of Diapers Needed
(Preemie to Pull-up Available)
Preemie
Size 0
Size 1
Size 2
Size 3
Size 4
Size 5
Size 6
Size 7
Size 2T-3T
Size 3T-4T
Size 4T-5T
Type of Registration
Upcoming Month ONLY
*This will require a new pre-registration
for any future pickups to be reserved
specifically for you
Ongoing Monthly Registration
*This will continue until client notifies
CKLECC of any changes. Diaper sizes
can be changed by filling out a new
pre-registration form.
Race
African
Black/African American
White/Caucasian
Hispanic/Latino
Native American
Bi-Racial/Multi-Racial
Other/Unknown
Prefer not to answer
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