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REV: 06-22-22 RL <br />Exhibit A <br />Enrollment Form <br />Bay Area Diaper Bank Enrollment Form <br />Please complete this Enrollment Form in order to participate in the Bay Area Diaper Bank, run <br />by Help a Mother Out, a California nonprofit public benefit corporation. <br />I.Agency Information: <br />Name of Location Distributing the <br />Diapers (referred to as the “Agency”): <br />II.Parent / Legal Guardian Information: <br />Name of Parent / Legal Guardian <br />First <br />Name <br />Last <br />Name <br />Primary Zip Code: <br />Name of program at the Agency that parent <br />is enrolled in (if applicable): <br />III.Child Information: <br />First <br />Name <br />Last <br />Name <br />Date of Birth Child <br />Current Diaper Size Child <br />ATTY/AGR.2022.161/Help a Mother Out (Help a Mother Out FYE 23 Contract) (Page 7 of 9)