Partner Application — Bundles of Joy

Partner Organization Application

Please fill out the form below to apply for partnership with Bundles of Joy NY.

You will need to upload a signed Agreement at the end of the application. You can click the button below to download the Agreement.

Questions? Contact Adrienne at adrienne@bundlesofjoyny.org

Partner Agreement

Organization Name

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Website

http://

Executive Director’s Name

Executive Director’s Phone with Extension

(###)

###

####

Executive Director’s Email

Your Agency is a:

Please Include Your Agency’s Mission Statement (one paragraph max)

Please Describe the Population Your Agency Serves

What is the Ethnic Composition? Include Percentages if Available (Must Total 100%)

African American or Black: ____ Asian: ___ Hispanic or Latino: ____ Native Hawaiian or Other Pacific Islander: ____ White: ____ Other: ____

Number of Children Served in the Following Age Groups (Yearly)

0-2: ____ 2-4: ___ 5-11: ____ 12+: ____ Mothers/Caregivers: ____

Description of Programs Using Diapers and Baby Supplies

Please describe your program that will be using Diapers and Baby Supplies. If you have more than one program that will use Diapers and Baby Supplies please copy this page and give a brief description of the service provided noting how the Diapers and Baby Supplies will be used in the program. Provide the contact person with direct phone extension, cell phone and email address for each program.

Program Name

Program Contact Person

Phone Number with Direct Extension:

(###)

###

####

Cell Phone Number

(###)

###

####

Program Description

Do You Measure Outcomes for Your Program?

How Will the Diapers and Baby Supplies be Used by This Program?

Select All That Apply

On-Site Residential Program

Emergency Supplies for Families (Off-Site)

Diapers and Baby Supplies to be Provided to Other Qualified Agency

Daycare

Other

Do you Receive Diapers and Baby Supplies From Other Sources? Please List.

Separate with Comma

Do You Have a Budget for Diapers and Baby Supplies?

Do You Currently Turn Away Clients Due to a Lack of Diapers and Baby Supplies?

Yes