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11451 Braddock Road, Fairfax VA 22030
Fairfax Responds: Resource Center Request Form
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We understand that these are challenging times of uncertainty and financial strain. To help ease the burden, the Resource Center is offering essential items for you and your family to include groceries, household and hygiene supplies, kitchen essentials, diapers and formula, if needed. To best assist you with resources, please complete the form below. Once submitted, we will confirm your selected pick-up time and provide any other necessary details. If you have any questions or need further assistance, please don't hesitate to reach out to us at resourcecenter@fairfax.cc.
Personal Information
(Required)
First Name
Last Name
Zip Code
(Required)
What is the best way to contact you for pickup confirmation?
(Required)
Please select
Email
Text
Cell Phone Number
(Required)
Email Address
(Required)
Select your pick-up date and time below:
(Required)
Do you need to make other arrangements for donation pickup?
(Required)
No, I will pick up the items at the date and time selected.
Yes, I need to coordinate with someone to make other arrangements for pick up.
Specifically, what other arrangements are you requesting? Someone from our team will reach out to you.
Family demographic breakdown for the ENTIRE household (Adult and Children)
Provide a detailed demographic breakdown of the entire household so we can best assemble resources to you.
How many males ages 11+ (including adults) are in the family?
(Required)
How many females ages 11+ (including adults) are in the family?
(Required)
How many children ages 0 to 36 months are in the family?
(Required)
How many children ages 3+ to 10 years are in the family?
(Required)
How can we assist you today?
Please check most immediate needs that apply.
Groceries
Please review the descriptions below and select the most appropriate option based on your needs.
Shelf-Stable Groceries
: For families or individuals who have access to a full kitchen and are inclined to prepare meals from a variety of available groceries (e.g., grains, canned goods, pasta). Perishables and frozen items are optional.
Family Meals:
For families or individuals with access to a full kitchen, but who prefer quick and easy-to-follow meal options.
Perishable items and frozen meals will be included.
Microwave Bag:
For families or individuals who only have access to a microwave and not a full kitchen and may need ready-to-heat meals and snacks.
Snacks (If available)
Would you like to include a bag of snacks for the family?
No
Yes
This field is hidden when viewing the form
Groceries OLD
Non-perishable food for a week (breakfast, lunch, and dinner)
Microwave only bag: non-perishable food for a week (breakfast, lunch, and dinner)
Perishable Bag
Refrigerator Bag: milk, eggs, bread, fruits, and vegetables
Frozen Bag: frozen meat and vegetables
Kitchen Essentials
Regular Bag: flour, sugar, oil, and salt
Culturally Appropriate Bag - Central America: Maseca, Goya brand items
Household and Hygiene
Household Essentials: toilet paper, paper towels, dish soap, hand soap, laundry detergent, cleaning wipes
Hygiene Supplies: shampoo, conditioner, body wash, deodorant, toothbrush, toothpaste
Feminine Products
This field is hidden when viewing the form
Household and Hygiene
Household Essentials: toilet paper, paper towels, dish soap, hand soap, laundry detergent, cleaning wipes
Hygiene Supplies: shampoo, conditioner, body wash, deodorant, toothbrush, toothpaste
Feminine Products
How many females are in need of pads?
(Required)
Please select
None
1
2
3
4
5
How many females are in need of tampons?
(Required)
Please select
None
1
2
3
4
5
Are there senior adults (age 65+) in the household in need of adult diapers?
No
Yes
Gender of the adult in need of adult diapers.
(Required)
Male
Female
Adult diaper size
(Required)
Small
Medium
Large
XLarge
XXLarge
Baby Essentials
Baby Food
Baby Formula
Baby Diapers
Baby Food
How many children need STAGE 1 baby food (4 to 6 months old)?
(Required)
NONE
1
2
3
How many children need STAGE 2 baby food (7 to 10 months old)?
(Required)
NONE
1
2
3
Baby Formula
What kind of formula does the family need? (Parent's choice brand)
(Required)
Parent's choice compares to Enfamil Infant
Parent's choice compares to Similac
Diapers
What size of diaper do the children in this household wear?
(Required)
Newborn diapers
SIZE 1 diapers
SIZE 2 diapers
SIZE 3 diapers
SIZE 4 diapers
SIZE 5 diapers
SIZE 6 diapers
Pull-ups
How many children are in NEWBORN diapers?
(Required)
Please select
1
2
3
How many children are in SIZE 1 diapers?
(Required)
Please select
1
2
3
How many children are in SIZE 2 diapers?
(Required)
Please select
1
2
3
How many children are in SIZE 3 diapers?
(Required)
Please select
1
2
3
How many children are in SIZE 4 diapers?
(Required)
Please select
1
2
3
How many children are in SIZE 5 diapers?
(Required)
Please select
1
2
3
How many children are in SIZE 6 diapers?
(Required)
Please select
1
2
3
Pull-ups size
(Required)
2T-3T (16-34 lbs)
3T-4T (32-40 lbs)
4T-5T (38-50 lbs)
5T-6T (46-60 lbs)
7T (65 lbs+)
How many children are in need of pull-ups size 2T-3T (16-34 lbs)?
(Required)
Please select
1
2
3
How many children are in need of pull-ups size 3T-4T (32-40 lbs)?
(Required)
Please select
1
2
3
How many children are in need of pull-ups size 4T-5T (38-50 lbs)?
(Required)
Please select
1
2
3
How many children are in need of pull-ups size 5T-6T (46-60 lbs)?
(Required)
Please select
1
2
3
How many children are in need of pull-ups size 7T (65 lbs+)?
(Required)
Please select
1
2
3
Additional Information
To assemble donations best adapted to your family, is there anything else we should be aware of or other requests we might be able to provide? Please be VERY SPECIFIC and understand we cannot guarantee these resources.
After you hit submit, you will receive a confirmation email that we received your request. Once your donation request is ready we will confirm pick up.
Please confirm below:
Comments
This field is for validation purposes and should be left unchanged.
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About
Our Vision & Mission
Leadership & Staff
Ministries
Children’s Ministry
Fairfax Business Accelerator
Fairfax College
Fairfax Creative
Global Impact
Outreach
Student Ministries
Resource Center
Fairfax Coffee
Fairfax Español
Accessibility
Job Openings
2024 Impact Report
Next Steps
New Here? Start Here!
Get Baptized
Join a Group
Get Care & Support
Classes at Fairfax
Serve With Us
Devotionals
Events
All Events
Watch
Join Us Live
Got a Minute?
Past Sermons
Giving
Give Now
Theology of Giving
Immeasurably More
Fairfax Responds
