Resource Request Form – Fairfax Church

11451 Braddock Road, Fairfax VA 22030

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 clothing 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.

SCHOOL, DIVISION, or UNIT within your agency(Required)

Professional Email Address(Required)

Cell Phone Number(Required)

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

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

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

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

If this is one of several orders you will be submitting for pick up on the same day, is there an identifier that we can use to help separate your donation pick up, (ie, "family initials)?

Family demographic

Tell us about family demographic 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

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 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

Does the client have a dishwasher?(Required)

Yes

How many females are in need of feminine products?(Required)

What type of products do you need?(Required)

Pads

Tampons

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? (Member's Mark brand)(Required)

Members Mark Infant compares to Enfamil Premium Infant

Other

Please specify other brand of formula

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)

Hidden

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)

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)

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?

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:(Required)

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.

Do you need someone to call you about retrieving your donations?(Required)

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

Yes, I need to make other arrangements.

Please confirm below:

Comments

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

FAQs

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 families maintain a sustainable living.

During the pandemic, we were inspired by so many professionals who were working outside the scope of their required job responsibilities to help families in crisis. We heard so many stories, from teachers buying groceries and dropping them off at students’ homes to counselors shopping on Christmas Eve, that we wanted to share the wealth of the financial burden to support professionals caring for these families.

What are the resources?

The resources in our center are meant for supplemental purposes and not as ongoing support services for families. The Northern Virginia area has numerous social service agencies and opportunities for families to get connected with professionals who can help. It is important for families to connect to these services so that they can work with a case worker toward sustainability.

Resources include groceries (perishables and non-perishables), hygiene items, household essentials, cleaning supplies, diapers and clothing.

How do requests work?

Let’s jump right to it. We are so excited to work with you!

First, complete the request form below with your professional name, professional email, agency, and cell phone.

Second, through the request form, we’ll ask for generic information about the family so we can pull together enough resources for the size and age range of the family. Next, we will ask you to let us know your availability to pick up the resources. All of these details will be confirmed over email/text before you arrive. Please make sure you receive this email/text before coming to the Resource Center.

Can Fairfax deliver 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 families toward sustainability. Therefore, we prefer that you pick up from our center which is open Monday through Thursday 9:00am – 5:00pm and Sunday mornings, by appointment. We can make arrangements for a delivery to be made to you per request in our 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.

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

Family demographic

How can we assist you today?

Baby Food

Baby Formula

Diapers

Children's Clothing 0-16 YEARS

Child #1

Child #2

Child #3

Child #4

Child #5

Other requests

Donation Pick-up

FAQs

Who are the professionals?

What are the resources?

How do requests work?

Can Fairfax deliver to my clients?

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