Diaper Distribution/Hopper Registration Intake Form 2025
If you are in need of diapers for your children, please fill out the intake form below to request supplies. Please note that each family can only receive diapers from Healthier Moms and Babies once a month. If you are in one of our programs, you will receive diapers through your home visitor and NOT through the mobile unit. *If your child is 5 or older, they cannot receive diapers/pull-ups without a doctor's note.
New Requirements 2025
**You must upload or bring your child’s birth certificate for all children you are requesting diapers for. ***The person registered must be the person picking up diapers and you must show your ID. You can no longer pick up diapers for others. ****For All ALLEN COUNTY residents, you must register AND attend a Hopper Group Education Class to be able to receive Free diapers due to funding requirements. To register for a class, use the "Click here for class registration!" button that can be found on the Healthier Moms and Babies website. This is on the same page that you register for an Allen County Hopper event. You will need to attend a class every 12 months to continue to receive diapers.
Your Name
*
First Name
Last Name
Your Phone Number
*
Your Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Email
*
example@example.com
I agree to accept text reminders from Healthier Moms and Babies.
*
I agree
Are you a current HMB client?
*
No
Yes
Did you receive diapers from your HMB home visitor this month? If yes, you are not eligible to receive diapers twice a month. Contact your home visitor for assistance.
No
Yes
Please tell us how you receive diapers from us (Select 1)
At Hopper events in the community
Through Fort Wayne Community Schools (current FWCS students ONLY)
Through a Brightpoint Head Start location
If you are a current FWCS student, please tell us which high school or middle school you are attending.
Please Select
CAS Nebraska
Career Academy
North Side
Northrop
Snider
South Side
Wayne
Blackhawk
Jefferson
Kekionga
Lakeside
Lane
Memorial Park
Miami
Northwood
Portage
Shawnee
Towles
If you are a Brightpoint Head Start family, please tell us which Head Start location you will be picking up diapers from.
Please Select
Anthony Head Start
Berne Head Start
Columbia City Head Start
East Wayne Street Head Start
Garrett Head Start
Hanna Creighton Head Start
Huntington Head Start
Kendallville Head Start
Reed Street Head Start
The Temple Head Start
Waterloo Head Start
Have you EVER registered for the Healthier Moms and Babies diaper program in the past? If so, please skip the remaining questions and click NEXT at the bottom of the page.*
*
No
Yes
The following forms of identification are required to receive assistance: Government Issued Photo ID (Driver’s License, State ID, Military ID, VISA, passport) for parent AND Birth Certificate (for every child in need of assistance) Please upload these TWO documents now or be prepared to bring them to the Diaper Mobile Outreach Event.
Browse Files
Cancel
of
Marital Status
*
Single
Married
Separated
Divorced
Widow
Social Security Number
Your Date of Birth
-
Month
-
Day
Year
Date
Race
*
White-Hispanic
White-Non Hispanic
Black/African American - Hispanic
Black/African American - Non Hispanic
Asian - Hispanic
Asian - Non Hispanic
American Indian/Alaskan Native - Hispanic
American Indian/Alaskan Native - Non Hispanic
Native Hawaiian/Other Pacific Islander - Hispanic
Native Hawaiian/Other Pacific Islander - Non Hispanic
American Indian/Alaskan Native & White - Hispanic
American Indian/Alaskan Native & White - Non Hispanic
Asian & White - Hispanic
Asian & White - Non Hispanic
Black/African American & White - Hispanic
Black/African American & White - Non Hispanic
Am. Indian/Alaskan Native & Black/African American - Hispanic
Am. Indian/Alaskan Native & Black/African American - Non Hispanic
Other Multi-Racial - Hispanic
Other Multi-Racial - Non Hispanic
What is the highest grade level of school that you have completed?
*
Grades 0 - 8
Some High School (Grades 9, 10, 11 & 12)
High School Diploma, GED, or Equivalency Diploma
Some College/Post-Secondary
College Graduate (Associates or Bachelors)
Graduate Degree or other Post-Secondary School
Declined to Answer
How did you hear about Healthier Moms and Babies?
*
Friend
Family member
Instagram
Facebook
Website
Other
Social Agency, please specifiy
If answered social agency to previous question, which one?
How many children in your household are under the age of 18?
*
How many adults are in your household?
*
Please Select
1
2
3
4
5
6
7
8
9
10
What is your annual income?
*
How many adults work outside of the home?
*
How many adults in your household are parenting at home (stay at home parents who are not working outside the home or looking for other work)?
*
How many adults in your household are currently looking for work?
*
How many adults in your household are students?
*
Are you a military family?
*
Yes
No
Veteran
Female head of household?
*
Yes
No
Disability?
*
Yes
No
Indicate which of the following have a disability.
*
Yes
No
Self
Child 1 receiving diapers
Child 2 receiving diapers
Child 3 receiving diapers
Child 4 receiving diapers
Is anyone in your household eligible for WIC/SNAP/Food Stamps?
*
Yes
No
Back
Next
Child Information
Please list the names of the children and what size diaper the child wears. Sizes must be provided.
CHILD 1
Child 1 Name
*
First Name (C1)
Last Name (C1)
Child 1 Date of Birth
*
-
Month
-
Day
Year
Date
Child 1 Gender
*
Male
Female
Other
Child 1 Diaper Size
*
Newborn
Size 1
Size 2
Size 3
Size 4
Size 5
Size 6
2T-3T Pullups
3T-4T Pullups
4T-5T Pullups
Do you have a 2nd child that needs diapers? If NOT, please skip the remaining questions and click NEXT at the bottom of the page.
*
Please Select
Yes
No
Child 2
Child 2 Name
First Name (C2)
Last Name (C2)
Child 2 Gender
Male
Female
Other
Child 2 Date of Birth
-
Month
-
Day
Year
Date
Child 2 Diaper Size
Newborn
Size 1
Size 2
Size 3
Size 4
Size 5
Size 6
2T-3T Pullups
3T-4T Pullups
4T-5T Pullups
Do you have a 3rd child that needs diapers? If NOT, please skip the remaining questions and click NEXT at the bottom of the page.
Please Select
Yes
No
Child 3
Child 3 Name
First Name (C3)
Last Name (C3)
Child 3 Date of Birth
-
Month
-
Day
Year
Date
Child 3 Gender
Male
Female
Other
Child 3 Diaper Size
Newborn
Size 1
Size 2
Size 3
Size 4
Size 5
Size 6
2T-3T Pullups
3T-4T Pullups
4T-5T Pullups
Do you have a 4th child that needs diapers? If NOT, please skip the remaining questions and click NEXT at the bottom of the page.
Please Select
Yes
No
Child 4
Child 4 Name
First Name (C4)
Last Name (C4)
Child 4 Date of Birth
-
Month
-
Day
Year
Date
Child 4 Gender
Male
Female
Other
Child 4 Diaper Size
Newborn
Size 1
Size 2
Size 3
Size 4
Size 5
Size 6
2T-3T Pullups
3T-4T Pullups
4T-5T Pullups
Back
Next
Supply Information & Signature
About how long have you been getting diapers from Healthier Moms and Babies?
*
this is my first time
a few weeks
about a month
a few months
several months
about a year
a few years
Receiving these diapers will help to reduce my stress
*
Please Select
Agree
Disagree
Receiving these diapers will allow me to go to work or school
*
Please Select
Agree
Disagree
Receiving these diapers will help me to purchase food for my family
*
Please Select
Agree
Disagree
Receiving these diapers will allow me to change my child’s diaper more often, making them happier
*
Please Select
Agree
Disagree
I feel stress about how I am going to afford diapers:
*
Please Select
Never
Rarely
Often
Always
How often do you find it challenging to afford an adequate supply of diapers for your child?
*
Please Select
Never
Rarely
Often
Always
My child has to go without clean diapers:
*
Please Select
Never
Rarely
Often
Always
Select a date and time that you would like to pick up diapers:
If you are unable to select a date and time, it means our events are currently full. Please check back for updates
ALLEN COUNTY: 3/25/2025 City Church 5300 Decatur Rd Fort Wayne, IN 46806 2:00pm-4:00pm
STEUBEN COUNTY: 4/2/2025 Fremont Community Church 601 N Coldwater St. Fremont, IN 46701 10:00am-12:00pm
WHITLEY COUNTY: 4/3/2025 South Whitley Farm Wagon 709 N. Hathaway Dr. South Whitley, IN 46787 (Fox Productions Parking lots)
ADAMS COUNTY: 4/7/25 Kroger Lot 929 S 13th St. Decatur, IN 46733 10am-11am
ALLEN COUNTY: 4/8/25 Neighborhood Health Clinic 3350 E Paulding Rd 11am-1pm
NOBLE COUNTY: Albion Farm Wagon 200 Weber Rd Albion, IN 46701 10:00 am- 12:00 am (Hidden Diamonds Park)
DEKALB COUNTY: Auburn Goodwill Industries 1003 W 7th St. Auburn, IN 46706 10:00am-12:00pm
ALLEN COUNTY: 4/15/2025 Salvation Army 2901 N Clinton St Fort Wayne, 46805 1:00pm-3:00pm
HUNTINGTON COUNTY: 4/16/25 Huntington Farm Wagon 1330 S. Jefferson St 2pm-4pm (Huntington County Health Department)
ALLEN COUNTY: 4/17/25 Woodburn Community Clothing Bank 22399 Hickory St. Woodburn, IN 46797 10 am- 12pm
WELLS COUNTY: 4/22/25 Bluffton Farm Wagon 428 S Oak St. Bluffton, IN 46714 10am-12 am (Life Community Church)
LAGRANGE COUNTY: 4/24/25 LaGrange WIC Department 304 N Townline Rd LaGrange, IN 46761 2pm-4pm
Allen County: 4/24/2025 Super Shots 1515 Hobson Rd Fort Wayne, IN 46805 5pm-7pm
ALLEN COUNTY: 4/26/25 Touch-a-truck Ivy Tech Community College 3800 N Anthony Blvd 46805 9am-11am
STEUBEN COUNTY: 5/7/25 Fremont Youth and Community Outreach 601 N Coldwater St. Fremont, IN 46737 10am-12pm
Whitley County: 5/8/2025 Whitley County WIC Office 543 N Line St. Columbia City, IN 46725
Allen County: 5/13/25 Neighborhood Health Clinic 3350 E Paulding Fort Wayne, IN 46816 11:00am - 1:00 pm
Dekalb County 5/14/25 : Dekalb County WIC Office 265 Grandstaff Dr. Auburn, IN 46706 2pm-3pm
Jay County: 5/15/25 Jay County Family Resource Center 827 West High St. Portland, IN 47371
Allen County: 5/16/25 Project.ME Drop-in Center 2305 Broadway Fort Wayne IN 46807 4pm-6pm
Allen County: 5/17/25 Pontiac Street Market 918 E Pontiac St. Fort Wayne, IN 46806 12pm-2pm
LaGrange County: 5/19/25 LaGrange County Health Department 826 N Detroit St. LaGrange, IN 46761 10am-12pm
ALLEN COUNTY: 5/20/25 Women's Care Center 921 Coliseum Blvd Fort Wayne, IN 46808 1:30 pm- 3:30pm
Adam County: 5/22/25 Adams County WIC office 313 W Jefferson St. Decatur, IN 46733
Allen County: 5/22/25 Super Shots 1515 Hobson Rd Fort Wayne, IN 46805 4pm-6pm
WELLS COUNTY: 5/27/25 Bluffton Farm Wagon 428 S Oak St. Bluffton, IN 46714 10am-12pm (Life City Church)
NOBLE COUNTY: 5/28/25 Ligonier Kroger/tractor supply 903 Lincoln Way S, Ligonier, IN 46767 10am-12pm
Noble County: 6/3/2025 Noble County WIC Office 774 Trail Ridge Rd. Albion, IN 46701 2pm-3pm
Steuben County: 6/4/2025 Fremont Youth and Community Outreach 601 N Coldwater St. Fremont, IN 46737
ALLEN COUNTY: 6/10/25 Neighborhood Health Clinic 3350 E Paulding Rd Fort Wayne, IN 46816 11am-1pm
ALLEN COUNTY: 6/11/25 New Haven Kroger 821 Lincoln Hwy, New Haven, IN 46774 10am-12pm
Whitley County: 6/11/2025 Whitley County WIC office 543 N Line St. Columbia City, IN 46725 1:30pm-3:30pm
Huntington County: 6/12/2025 Huntington United With Love of Huntington County 715 Byron St. Huntington, IN 46750 2:30-3:30 pm
Dekalb County: 6/17/25 Auburn Goodwill Industries 1003 W 7th St. Auburn, IN 46706 10am-12pm
Allen County: 6/17/25 Salvation Army 2901 N Clinton St. Fort Wayne, IN 46805 1pm-3pm
Adam County: 6/18/2025 Adams County WIC office 313 W Jefferson St. Decatur, IN 46733 10am-12pm
Jay County: 6/18/2025 Jay County Family Resource Center 827 West High St. Portland, IN 47371 2pm-4pm
Wells County: 6/24/25 Wells County Farm Wagon 428 S Oak St Bluffton, IN 46714 (Life City Church) 10am-12pm
Allen County: 6/24/25 City Church 5300 Decatur Rd Fort Wayne, IN 46806 2:30pm-4:30pm
Allen County: 6/26/25 Super Shots 1515 Hobson Rd Fort Wayne, IN 4pm-6pm
LaGrange County: 6/26/25 LaGrange County WIC office 304 N Townline Rd 46761 12pm-2pm
Steuben County: 7/2/2025 Fremont Youth and Community Outreach 601 N Coldwater St. Fremont, IN 46737 10am-12pm
Allen County: 7/8/2025 Neighborhood Health Clinic 3350 E Paulding Rd. Fort Wayne, IN 46816 11am-1pm
Dekalb County: 7/9/2025 Dekalb County WIC Office 265 N Grandstaff Dr. Auburn, IN 46706 2pm-3pm
Whitley County: 7/10/2025 Whitley County WIC office 543 N Line Rd Columbia City, IN 46725 2pm-3pm
Allen County: 7/15/2025 Women's Care Center 921 W Coliseum Blvd Fort Wayne, IN 46808 1pm-3pm
Huntington County: 7/16/2025 Huntington County Food Pantry 715 Byron St. Huntington, IN 46750 11am-1pm
Noble County: 7/16/25 Community Baby Fair 401 E Diamond St. Kendallville, IN 46755 4pm-7pm
Adams County: 7/17/2025 Adams County WIC office 313 W Jefferson St. Decatur, IN 46733 10am-12pm
Jay County: 7/17/2025 Jay County Family Resource Center 827 W High St. Portland, IN 47371 2pm-4pm
Allen County: 7/19/2025 Pontiac Street Market 918 E Pontiac St. Fort Wayne, IN 46806 12pm-2pm
Wells County: 7/22/2025 Life City Church 428 S Oak St. Bluffton, IN 46714 10am-12pm
Allen County: 7/22/2025 City Church 5300 Decatur Rd Fort Wayne, IN 46806 2pm-4pm
Noble County: 7/23/2025 Kroger/Tractor Supply 903 Lincoln Way S. Ligonier, IN 46767 10am-12pm
LaGrange County: 7/24/25 LaGrange County WIC office 304 N Townline Rd LaGrange, IN 46761 12pm-2pm
Allen County:7/24/2025 Super Shots 1515 Hobson Rd Fort Wayne, IN 46806 4pm-6pm
Allen County: 8/2/2025 Pontiac Street Market Back to School Event 918 E Pontiac St. Fort Wayne, IN 46806 11am-2pm
Noble County: 8/5/2025 Noble County WIC Office 774 Trail Ridge Rd. Albion, IN 46701 1pm-2pm
Stueben County: 8/6/2025 Fremont Youth and Community Outreach Center 601 N Coldwater St. Fremont, IN 46737 10am-11am
Huntington County: 8/6/2025 United With Love of Huntington County 715 Byron St. Huntington, IN 46701 1pm-2pm
Allen County: 8/12/2025 Neighborhood Health Clinic 3350 E Paulding Rd Fort Wayne, IN 11am-1pm
Allen County: 8/12/2025 The Salvation Army 2901 N Clinton St. Fort Wayne, IN 2pm-4pm
Whitley County: 8/13/2025 Whitley County WIC Office 543 N Line St. Columbia City, IN 1pm-2pm
Adams County: 8/14/2025 Adams County WIC office 313 W Jefferson St. Decatur, IN 46733 11am-12pm
Jay County: 8/14/2025 Jay County Family Resource Center 827 W High St. Portland, IN 47371 2pm-3pm
Dekalb County: Goodwill Industries 1003 W 7th St. Auburn, IN 46706 11am-12pm
Woodburn: 8/21/2025 Woodburn Clothing Bank 22399 Hickory St. Woodburn, IN 10am-11am
Allen County: 8/21/2025 Super Shots 1515 Hobson Rd Fort Wayne, IN 4pm-6pm
Wells County:8/26/2025 Bluffton Farm Wagon 428 S Oak St. Bluffton, IN 46714 10am-11am
Allen County: 8/26/2025 City Church 5300 Decatur Rd Fort Wayne, IN 2pm-4pm
LaGrange County: 8/28/2025 LaGrange County WIC Office 304 N Townline Rd. LaGrange, IN 12pm-1pm
What areas would you like receive additional information: (Select all that apply)
*
Food assistance
Housing/shelter assistance
Employment/jobs training
Mental health counseling
Transportation
Healthcare
Sobriety/recovery support
Interpersonal violence
None
Other
If you received diapers from the Hopper in the past, how would you rate your service?
Excellent
Good
Fair
Below average
Poor
Is there anything else you would like Healthier Moms and Babies to know?
All the assistance that we offer to families is free of charge. There are no income or employment requirements for families in need of assistance; however, we do require all clients to complete the intake form and provide the required identification in order to receive any items from us. If a client is receiving assistance from another agency that happens to be one of our partners, the client will not be permitted to receive direct service from us as well. The client agrees to indemnify, defend, and hold harmless Healthier Moms and Babies from any and all liabilities for the items received. Furthermore, the client hereby forever releases, and discharges Healthier Moms and Babies, its officers, directors, and volunteers from any and all claims for any known, unknown, or future damages because of the quality of the gently used items received. Healthier Moms and Babies reserves the right to refuse service to a client if they do not adhere to these terms and guidelines as outlined, or if any information submitted on the client intake form is found to be false or inaccurate.
*
I hereby agree not to sell these diapers and acknowledge that, by doing so, I will forfeit the opportunity to receive additional diapers in the future.
I have read and agree to the terms, guidelines for assistance and distribution policy as outlined above.
Please Sign
*
Date
*
-
Month
-
Day
Year
Date
Back
Next
Submit
Back
Next
For Office Use Only
SUBMIT YOUR REQUEST.
Received diapers in (select months). To be completed by staff only.
January
February
March
April
May
June
July
August
September
October
November
December
Type the number of diapers provided for each month by size. To be completed by staff only.
Preemie
Newborn
1
2
3
4
5
6
2T-3T
3T-4T
4T-5T
January
February
March
April
May
June
July
August
September
October
November
December
Should be Empty: