Please complete this form if you'd like to learn more about establishing a local Allied Program or becoming an Allied Program. We're excited to help you adapt the APS program model to fit your organizational culture in order to help more people access basic needs.

What is the current status of your program?

We currently collect and distribute period supplies.We are interested in collecting and distributing period supplies.

What was your first period supplies distribution date? Format MM/DD/YYYY

What types of period products do (or will) you distribute? Select all that apply.

PadsLinersTamponsReusable CupReusable Cloth PadsOther Item Not Listed

How often do (or will) you distribute period supplies? (If more than one, select the most common)

WeeklyAlternate Weeks or Twice MonthlyMonthlyQuarterly

How do (or will) you distribute period supplies?

Direct to individualsThrough partner agenciesBoth to individuals and through agencies.

How many partner agencies do you expect/hope to give period products to this year? (So far, members who've responded estimate 1-40 partner agencies this year.)

About how many individuals per month do you expect/hope to give period products to this year? (So far, members who've responded estimate 25-500 individuals per month.)

How many counties would your program aim to serve this year? (So far, members who've responded estimate 1-10 counties.)

Proposed Local APS: Tell us the city, county or geographical area you plan to serve in as few words as possible.

Please add any additional comments or questions you may have.

First Name

Last Name

Organization

City

Zip Code

State

Need assistance with this form?

National Diaper Bank Network

155 East Street - Suite 101

New Haven CT 06511

203-821-7348