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Form Testing
Welcome! We are so happy you found the Fairfax Church Resource Center. We provide resources to Community Professionals working directly with families who need immediate support. If you are a professional and currently need to obtain resources for a family, we want to support you.
Professional Information
*
First Name
Last Name
What type of agency do you work for?
*
Please select
Department of Family Services
FCPS-HLO
JDRDC
Public School System
Fairfax County Police Department
Nonprofit Organization
Other
You must work for a nonprofit, school, or government service agency.
Name of school, agency, or organization
*
Professional Email Address
*
Cell Phone Number
*
What is the best way to contact you?
*
Please select
Email
Call
Text
Client Information
Thank you for all that you do to support the most vulnerable families in our community. Tell us a little bit more about the immediate needs of your client and the family demographic so we can better assemble resources for you. PLEASE DO NOT COMBINE REQUESTS ONTO ONE FORM. ONE REQUEST PER FAMILY.
What is the zip code or neighborhood that your client lives in?
*
How can we assist you today?
*
Please check most immediate needs that apply.
Groceries (non-perishable food for a week--breakfast, lunch, and dinner)
Perishables (milk, eggs, and bread, fresh and frozen fruits and vegetables)
Kitchen Essentials (flour, sugar, oil, and salt)
Home Essentials (toilet paper, paper towels, dish soap, Hand soap, laundry detergent, cleaning supplies)
Hygiene Supplies (shampoo, conditioner, body wash, deodorant)
Baby Essentials (diapers and food)
Other
Some substitutions and modifications available are listed below. Please select any that are applicable to this family.
Culturally Appropriate Bag - Latino
Culturally Appropriate Bag - Afghan
Some substitutions and modifications available are listed below. Please select any that are applicable to this family.
Only include food that can be cooked in a microwave
Please describe the OTHER assistance needed.
Is anyone in the household currently sick?
*
Yes
No
We can provide some additional foods for sick individuals; does not include medication.
How many males ages 13+ will you need resources for?
*
How many females ages 13+ will you need resources for?
*
How many children (12 and under) will you need resources for?
*
Diapers
For each diaper size below, indicate the number of children in this household who wear that size of diaper.
How many children are in NEWBORN diapers?
*
None
1
2
3
4
5
How many children are in SIZE 1 diapers?
*
None
1
2
3
4
5
How many children are in SIZE 2 diapers?
*
None
1
2
3
4
5
How many children are in SIZE 3 diapers?
*
None
1
2
3
4
5
How many children are in SIZE 4 diapers?
*
None
1
2
3
4
5
How many children are in SIZE 5 diapers?
*
None
1
2
3
4
5
How many children are in SIZE 6 diapers?
*
None
1
2
3
4
5
Baby Food
Does the family need formula (Similac Advance Formula)?
*
No
Yes
How many children need STAGE 1 baby food (4 to 6 months old)?
*
None
1
2
3
4
5
How many children need STAGE 2 baby food (7 to 10 months old)?
*
None
1
2
3
4
5
Additional Hygiene Products
Are there females in the family in need of feminine products?
*
No
Yes
How many females in need of feminine products?
*
1
2
3
4
5
What type of products do you need?
*
Pads
Tampons
Are there senior adults (age 65+) in the household?
*
No
Yes
Number of MALES in need of adult diapers?
*
None
1
2
3
Size for MALE adult diapers
*
Number of FEMALES in need of adult diapers?
*
None
1
2
3
Size for FEMALE adult diapers
*
Are there any specifics about the requests that we should be aware of?
Donation Pick-up
The Resource Center is open for you
Sunday through Thursday 9:00am – 5:00pm, by appointment only.
Select your pick-up date and time below:
*
The person picking up the donations should be the same professional filling out this form unless you specifically make other arrangements with the Resource Center team.
Do you need someone to call you about retrieving your donations?
*
No, I will pick up the items at the date and time selected.
Yes, I need to make other arrangements.
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Comments
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About
Vision & Mission
Children’s Ministry
Student Ministries
College & Young Adults
Fairfax Worship
Fairfax Español
Accessibility
Open Positions
A Message From Rod
Next Steps
New Here? Start Here!
Small Groups
Community Care
Serve With Us
Baptism
Child Dedication
Local Outreach
Global
Fairfax Fellows
Trellis Internship
Events
Summer at Fairfax
All Events
Watch
Watch Live
Past Sermons
Renovate
My Fairfax
