Cheyenne-Kiowa-Lincoln Early Childhood Council
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Diaper BAnk Pre-Registration
Date
Phone Number
Name
Email
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 2T-3T
Size 3T-4T
Size 4T-5T
Wipes
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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