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Partnership Application Form 

The following is an online version of our Partnership Application  Form. 

 

Please read it over and if you would like to join our team, fill the  form out and press the "Submit" button found at the end of the form. Also, fill in the "Submitter's Name" and "Submitter's Email Address". A verification email will be sent to you to verify that you did submit the form.

Sample Web Form
Hope Charitable Services Greater Hampton Roads Diaper Bank is a 501(c)(3) nonprofit charitable organization that exists to help partner agencies working with families in crisis meet their need for diapers.  Diapers are provided at no charge to approved partner agencies.  The quantity of diapers available for distribution is dependent upon donations to the Greater Hampton Roads Diaper Bank. This is a leap of faith for us and we will continue it as long as we are able to sustain the program. We are continuing to look for local sponsors for financial support

Greater Hampton Roads Diaper Bank reserves the right to decline an application based on a variety of criteria and

community need

During the application process a site visit and/or agency review may be requested.

Please tell us more about your organization, the social service(s) you provide and some general information about your average diaper needs (numbers of families you serve with diaper needs, sizes needed, frequency of distribution, etc.):
Organization Name
Mailing Address:
Web Address:
Directors Name:
Directors Phone:  Directors Email: 
Contact (If different):
Contact Phone:    Contact Email:  
Agency Mission:
Brief description of what your organization
does & what counties/areas you serve:
How does having diapers effect your mission?:

How will you decide if a client is eligible for diapers?

 

(Please include a copy of your paper work used to determine this).

How will the diapers be used?

        On site residential program

        Emergency supplies for families (off-site_

        Diapers to be supplied to other qualified agencies through your programs       

        Other ({;ease explain)  

Approximately how many families/people in need of diapers do
you serve each
year      
What size diapers do you typically need (infant, toddler, adult)?  
How frequently do you typically distribute diapers?       
Diapers are stored & distributed from a location in Virginia Beach, VA –        
can you pick up?            Yes         No
Days of the week you are most available for pick up?    
 (circle all that apply)
               Mon  Tue  Wed  Thu  Fri  Sat  Sun 

 Please email a copy of your501(c) (3) tax-exempt determination letter to:

cher.leadbeater@hopecharitable.org

or a letter on your state agency or designated religious organization’s letterhead.  Letter of Good Standing from National/Regional Headquarters (If Applicable). Also include a copy of your business card and current brochure or program information.

 

 

What we ask of our partners:

1.     All diapers provided by the Diaper Bank  are to be distributed directly to your clients without charge.

2.    Acknowledgement that the Diaper Bank may reject  or cancel partnership at any time due to lack of resources, failure to comply with the terms  of this  Partnership Agreement, or upon majority vote by Hope Charitable Services Board of Directors.

3.    Basic demographics are recorded on your part so that the Greater Hampton Roads diaper Bank may gather, upon request, information about how many individuals and/or families were served by the diapers we provided.  Failure to provide information may result in removal from the Diaper Distribution Network.

4.    To complete no less than two activities from the Collaborative Partnership list contained in this document

 

Please read and acknowledge:

Diaper Bank  items may not be sold, bartered or exchanged.  Items received from the Diaper Bank may not be taken by volunteers, officers, clergy or employees for personal use.  As outlined in the Internal Revenue Code Section 170(e) (3), all items you receive from the Diaper Bank  must be used solely for the care of the ill, needy or minors, pursuant to your organization's charitable purpose.

Partner Agencies hereby indemnify, defend and hold harmless Hope Charitable Services Greater Hampton Roads Diaper Bank from any and liabilities for the quality and safety of the product  consisting of diapers/incontinence supplies received as donations or purchased  by the Diaper Banik and then given to the Partner Agency. The Partner Agency hereby and forever releases and discharges the Diaper Bank, its offices, directors and/or employees from any and all claims for any know, unknown or future, because of the quality or safety of the products.

Collaborative  Partnership

 

  Provide financial contribution $

Volunteer at Hope Charitable Services (Min 10 HRS)

Serve on our Board of Directors or Committees

 Host a diaper drive for us through your agency

 Have your board members host a diaper drive for us at their places of employment

Include an article about Hope Charitable Services Greater Hampton Roads Diaper Bank in your agency's news letter at least once a year encouraging your supporters to donate diapers.

Send an email with info about Hope Charitable Services Greater Hampton Roads Diaper Bank to your supporters

Collaborate with Hope Charitable Services Greater Hampton Roads Diaper Bank on Grants and Fundraising.

Place a link to "hopecharitable.org" on your website (A logo will be provided).

Have a member of your staff speak at two community events with a Hope Charitable Services Greater Hampton Roads Diaper Bank representative (to be coordinated by Hope Charitable Services)

Additional ideas for collaborative partnership (beyond word of mouth).

                       I have read and agree to the above statements.

         May we place your organization’s logo & a link to your website on our site?   Yes      No

         How did you hear about Diaper Bank?
       Signature of organization Director:       Date:

PLEASE NOTE:  New partners will be activated as resources allow.

Potential partners are encouraged to submit an application, which will be date-stamped and kept on file.

As resources allow, partners will be activated, notified and will receive the diaper request form.

 

Diaper Distribution Volume

How many diapers do you give out MONTHLY? 

What size diapers do you distribute the most? 

 

Child and Family Information

How many children do you serve MONTHLY?  

 How many families do you serve MONTHLY?  

 

What % of the children you served this period are African-American? 

What % of the children you served this period are Asian?    
What % of the children you served this period are Hispanic?
 What % of the children you served this period are Native-American?      
What % of the children you served this period are White Non-Hispanic?    
What % of the children you served this period are Other ethnic group?      
What % of your population served is below poverty level (less than         
$22,330 for family of four)?
What % of your population served is low income (less than   
$44,700 for family of four)?
Submitter Name:   Submitter Email: 
 
 

Prior to depressing the "Submit" key you can print a copy of the completed Form by

depressing the following Print button.  

print

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(click on the following which will bring up HOPE's donation page)
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Hope Charitable Services • P.O. Box 7816 • Portsmouth, VA 23707-0816

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