Fairfax Responds: Resource Form

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We understand that these are challenging times of uncertainty and financial strain. To help ease the burden, the Resource Center is offering essential items for you and your family to include groceries, household and hygiene supplies, kitchen essentials, diapers and formula, if needed. To best assist you with resources, please complete the form below. Once submitted, we will confirm your selected pick-up time and provide any other necessary details. If you have any questions or need further assistance, please don't hesitate to reach out to us at resourcecenter@fairfax.cc.

Personal Information(Required)

First Name Last Name

Zip Code(Required)

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

Cell Phone Number(Required)

Email Address(Required)

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 coordinate with someone to make other arrangements for pick up.

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

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 to you.

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

Please review the descriptions below and select the most appropriate option based on your 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?

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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

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

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)

Additional Information

To assemble donations best adapted to your family, is there anything else we should be aware of or other requests we might be able to provide? Please be VERY SPECIFIC and understand we cannot guarantee these resources.

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.

Fairfax Responds: Resource Center Request Form

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

How can we assist you today?

Baby Food

Baby Formula

Diapers

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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