Resource Center TEST Form – Fairfax Church

Step 1 of 4

URL

This field is for validation purposes and should be left unchanged.

Welcome! We are so happy you found the Fairfax Church Resource Center. We provide resources to community social service professionals working directly with families who need immediate support.

Each week our Resource Center distributes groceries, household essentials, kitchen essentials, hygiene bags, diapers and special requests to some of the most vulnerable children and families in Fairfax County.

If you are a professional and currently need to obtain resources for a family, we want to support you. Simply submit the form below and you will receive an email confirmation from us. If you have any other questions, please contact us at resourcecenter@fairfax.cc.

Professional Information(Required)

First Name Last Name

What type of agency do you work for?(Required)

You must work for a nonprofit, school, or government service agency.

HHS: Agency type(Required)

FACETS: Agency Type(Required)

Shelter House: Agency Type(Required)

FCPS: Division or School(Required)

Non Profit: Organization(Required)

FCPD: Unit, District(Required)

Which station do you work in?(Required)

What is the FACETS agency type?(Required)

What is the HHS agency type?(Required)

What is the Shelter House agency type?(Required)

What is the name of the school?(Required)

What's the name of the Non Profit?(Required)

What is the best way to contact you for pickup confirmation?(Required)

What is the best way to contact you for further questions?(Required)

Professional Email Address(Required)

Please provide the email address and phone number of the person submitting this form so we can contact them with any clarification questions we may have.

Cell Phone Number(Required)

Donation Pick-up

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. We currently do not have a delivery system.

Select a pick-up time and date below:(Required)

CSP Donation Pick-up

The person picking up the donation should be the client receiving this donation, unless you specifically make other arrangements with the Resource Center team. We currently do not have a delivery system.

Select your pick-up date and time below:(Required)

Pick-Up Arrangements

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 make other arrangements.

Specifically, what other arrangements are you requesting? Someone from our team will reach out to you.

Volunteer Name(Required)

Volunteer Email Address(Required)

Social Worker Name(Required)

Client First Name(Required)

Client Last Name(Required)

Client Phone Number(Required)

Please provide a phone number we can use to confirm the pickup.

Client Case Number:(Required)

FY 2025 Income Limits Summary
Persons in Family	Extremely Low Income (30% MSA*)	Very Low Income (50% MSA*)	Low Income (80% MSA*)
1	$34,450	$57,400	$74,800
2	$39,350	$65,600	$85,450
3	$44,250	$73,800	$96,150
4	$49,150	$81,950	$106,800
5	$53,100	$88,550	$115,350
6	$57,050	$95,100	$123,900
7	$60,950	$101,650	$132,450
8+	$64,900	$108,200	$141,000

This is a test form – it will not send an update to the spreadsheet! It will still send the admin notification and set an appointment.

RC TEST FORM 2026

Welcome! We are so happy you found the Fairfax Church Resource Center. We provide resources to community social service professionals working directly with families who need immediate support.

Donation Pick-up

CSP Donation Pick-up

Pick-Up Arrangements

Client Information: PLEASE DO NOT COMBINE REQUESTS ONTO ONE FORM. ONE REQUEST PER HOUSEHOLD.

Client Identifier

Family demographic breakdown for the ENTIRE household (Adult and Children)

How can we assist you today? Please check most immediate needs that apply.

Baby Food

Baby Formula

Diapers

Children's Clothing 0-16 Years

Is the family in need of children's clothing? We have an inventory of donated clothing. We cannot guarantee we have the sizes you need, but we would love to offer them to your families. Please indicate below if your family needs clothing.

Child #1

Child #2

Child #3

Child #4

Child #5

Family Coats

We have an inventory of donated coats. We cannot guarantee we have the sizes you need, but we would love to offer them to your families. Please indicate below if your family needs coats.

Additional Information

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.

* 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 with the client based on the phone number provided.

ABOUT

NEXT STEPS

RESOURCES

SERVICE TIMES