RC Lifeline Form – Fairfax Church

11451 Braddock Road, Fairfax VA 22030

Resource Center Lifeline Request Form

Welcome! We are so happy you found the Resource Center at Fairfax Church. Our Lifeline Program provides resources to social service professionals working directly with individuals facing chronic food and economic insecurity.

Through this program our Resource Center distributes perishable food and frozen meat to some of the most vulnerable individuals in Northern Virginia whom for a variety of reasons
have limited to no access to services supporting long-term stability.

If you are a professional and currently need to obtain resources for an individual or 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.

Who are the professionals?

“Professional” is a broad definition for those in our community who work directly with families in crisis. This may include school and county social workers, teachers, police officers, parole counselors, resettlement agencies, the health department, counselors, doctors, nurses, among so many others. Professionals are working directly with people in difficult circumstances to help reduce food and economic security.

How do requests work?

Please complete the request form below and select your available time to pick up the resources. All of these details will be confirmed over email 24 hours before your scheduled pick-up. Please make sure you receive this email before coming to the Resource Center.

Our Lifeline Program exists to provide vital ongoing perishable food and frozen meat to individuals who have exhausted all other services. We will work with professionals to provide monthly support to these identified individuals along with an ongoing assessment plan.

Can you deliver directly to my clients?

No. We recognize that professionals hold relationship and trust with families, but not necessarily the budget to support all of their clients. We believe that providing professionals with supplemental resources relieves some of the stress so that you can better serve individuals in our Lifeline Program. Therefore, we prefer that you pick up from our center which is open Sunday through Thursday by appointment. We can make arrangements for your client to pick up in certain cases as needed and pre-arranged.

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You can access our Privacy Policy and Terms & Conditions here. The Resource Center will never share your information without your consent.

Professional Information

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

Your Name(Required)

First Name Last Name

Professional Email Address(Required)

Cell Phone Number

Text Message Agreement

By checking this box, I agree to receive transactional SMS messages from the Resource Center related to my request, including pickup scheduling, confirmations, and updates. Messaging frequency may vary. Message and data rates may apply. Reply HELP for help or STOP to opt-out. View our Privacy Policy and Terms of Conditions at https://fairfax.cc/resourcecenter/privacy/.

Yes, I agree.

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

FACETS Agency Type:

Facets: Other Agency

FCPD Agency Type:

FCPD: Other Dept

FCPS Agency Type:

FCPS: Other School

FBI Agency Type:

FBI: Other Agency

HHS Agency Type:

HHS: Other Agency

Nonprofit Agency Type:

Nonprofit: Other Org

Shelter House Type:

Shelter House: Other

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

Text Message

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

Text Message

Schedule a Pick-Up Appointment

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.

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Booker Master Setup

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Appt Type: Lifeline

Pick up Date and Time(Required)

Do you need to make other arrangements for donation pickup?(Required)

No, I will pick up the items at the selected date and time.

Yes, I will need to make other arrangements.

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

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Volunteer Name(Required)

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Volunteer Email(Required)

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Social Worker Name(Required)

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Client Name(Required)

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Client Phone Number(Required)

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

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Client Case Number:(Required)

Who are the professionals?

How do requests work?

Can you deliver directly to my clients?

Professional Information

Schedule a Pick-Up Appointment

Client Information

Additional Information

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