TEST Resource Center Form – Fairfax Church

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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.

Non Profit: Organization(Required)

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

Cell Phone Number(Required)

Professional Email Address(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 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 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 Information: PLEASE DO NOT COMBINE REQUESTS ONTO ONE FORM. ONE REQUEST PER HOUSEHOLD.

For the purposes of reporting back to our grant supporters, please complete the following regarding your client.

Thank you for all that you do to support the most vulnerable families in our community.

Client Identifier

What is the zip code or neighborhood that your client lives in?(Required)

Is the zip code in Fairfax County?(Required)

Head of House First Name or Initial(Required)

Head of House Last Name or Initial(Required)

Head of House Gender(Required)

DUPLICATED REQUESTS(Required)

IS THIS THE FIRST TIME, in 2025, that you have requested resources (from Fairfax Resource Center) for THIS FAMILY SPECIFICALLY?

Duplicated requests for the CURRENT MONTH(Required)

IS THIS THE FIRST TIME, in the current month, that you have requested resources (from Fairfax Resource Center) for THIS FAMILY SPECIFICALLY?

How would you describe your client's ethnicity?(Required)

How would you describe your client's race?(Required)

Check all that apply in describing your client's circumstances.(Required)

Disabled

Elderly (55 or older)

There is person (s) in the household over the age of 18 and unemployed.

Enrolled with SNAP

Enrolled with TANF

Limited access to food source (store, food bank, farmers market)

N/A

Check all that apply for the reason why your client can't access food sources.(Required)

Lack of transportation

Physical/Mental Health reasons

Availability of food bank during working hours or school hours

Other

How many TOTAL people are in the household (adults and children)?(Required)

How many adults age 18 and over are in the household?(Required)

FY 2024 Income Limits Summary
Persons in Family	Extremely Low Income	Very Low Income (50% MSA*)	Low Income (80% MSA*)
1	$32,500	$54,150	$68,500
2	$37,150	$61,900	$78,250
3	$41,800	$69,650	$88,050
4	$46,400	$77,350	$97,800
5	$50,150	$83,550	$105,650
6	$53,850	$89,750	$113,450
7	$57,550	$95,950	$121,300
8+	$61,250	$102,150	$129,100

* Washington, D.C., Metropolitan Statistical Area (MSA) MSA Median Family Income is $154,700.

Based on the table below, describe the client's income level.(Required)

Extremely Low Income

Very Low Income

Low Income

Other

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 for them.

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

The Resource Center is offering NEW options for social workers to choose from based on the unique circumstances of the individuals or families being served. Please review the descriptions below and select the most appropriate option based on the recipient's 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?

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

Is the family restricted to Halal?(Required)

Yes

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

Does the client have a dishwasher?(Required)

Yes

How many females are in need of pads?(Required)

How many females are in need of tampons?(Required)

Are there senior adults (age 65+) in the household in need of adult diapers?

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)

How many children need STAGE 2 baby food (7 to 10 months old)?(Required)

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)

How many children are in SIZE 1 diapers?(Required)

How many children are in SIZE 2 diapers?(Required)

How many children are in SIZE 3 diapers?(Required)

How many children are in SIZE 4 diapers?(Required)

How many children are in SIZE 5 diapers?(Required)

How many children are in SIZE 6 diapers?(Required)

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)

How many children are in need of pull-ups size 3T-4T (32-40 lbs)?(Required)

How many children are in need of pull-ups size 4T-5T (38-50 lbs)?(Required)

How many children are in need of pull-ups size 5T-6T (46-60 lbs)?(Required)

How many children are in need of pull-ups size 7T (65 lbs+)?(Required)

Children and Teens' socks and underwear

Is the family in need of children and teens' socks and underwear? We have an inventory of donated socks and underwear. 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 socks and underwear.

Is the family in need of children's socks and underwear?(Required)

Yes

How many children are in need of socks and underwear?(Required)

Child #1

What is the age of the child?(Required)

Gender for child #1(Required)

Male

Female

Socks Size(Required)

Don't need

XSmall

Small

Medium

Large

Underwear Size(Required)

Child #2

What is the age of the child?(Required)

Gender of child #2(Required)

Male

Female

Socks Size(Required)

Don't need

XSmall

Small

Medium

Large

Underwear Size(Required)

Child #3

What is the age of the child?(Required)

Gender(Required)

Boy

Girl

Season(Required)

Spring/Summer

Fall/Winter

Size(Required)

Child #4

What is the age of the child?(Required)

Gender(Required)

Boy

Girl

Season(Required)

Spring/Summer

Fall/Winter

Size(Required)

Child #5

What is the age of the child?(Required)

Gender(Required)

Boy

Girl

Season(Required)

Spring/Summer

Fall/Winter

Size(Required)

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.

Is the family in need of coats?

Yes

How many coats do you need?(Required)

Coat#1: Gender(Required)

Male

Female

Coat#1: Age(Required)

Coat#1: Size(Required)

Coat#2: Gender(Required)

Male

Female

Coat#2: Age(Required)

Coat#2: Size(Required)

Coat#3: Gender(Required)

Male

Female

Coat#3: Age(Required)

Coat#3: Size(Required)

Coat#4: Gender(Required)

Male

Female

Coat#4: Age(Required)

Coat#4: Size(Required)

Coat#5: Gender(Required)

Male

Female

Coat#5: Age(Required)

Coat#5: Size(Required)

Coat#6: Gender(Required)

Male

Female

Coat#6: Age(Required)

Coat#6: Size(Required)

Coat#7: Gender(Required)

Male

Female

Coat#7: Age(Required)

Coat#7: Size(Required)

Coat#8: Gender(Required)

Male

Female

Coat#8: Age(Required)

Coat#8: Size(Required)

Coat#9: Gender(Required)

Male

Female

Coat#9: Age(Required)

Coat#9: Size(Required)

Coat#10: Gender(Required)

Male

Female

Coat#10: Age(Required)

Coat#10: Size(Required)

Additional Information

To assemble donations best adapted to this family, is there anything else we should be aware of or other requests we might be able to provide? Please be VERY SPECIFIC with your requests.

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.

TEST Resource Center Request Form

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

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?

Baby Food

Baby Formula

Diapers

Children and Teens' socks and underwear

Is the family in need of children and teens' socks and underwear? We have an inventory of donated socks and underwear. 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 socks and underwear.

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.

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