Mask Request Form

Mask Request Form

Philly Breathes aims to serve the most marginalized Philadelphians. We try to do this by providing masks and education about COVID and other airborne diseases to people who are historically left behind and under-served.
Check out our Linktree for links to our social media and other resources!

We may take 1 to 3 weeks to get masks to you, so please plan for that!

Please only give the name that you are comfortable giving us. No legal names needed!
Are you located in Philadelphia, PA, USA?*

YesNo (please check out CovidActionMap.org for your closest mask bloc instead. We may be able to mail to individuals around the greater Philly area in a very limited capacity.)
Name & Pronouns

NamePronouns (Optional)
Contact Info (email, phone number, Instagram handle, or TikTok handle – wherever you are most reachable)*
example@example.com or (123) 456-7890 or @example
Zip Code
Who is the request for?*

Individual / Family / HouseholdOrganizationOther
If you're an org requesting masks, who do you primarily serve?
How many masks (in total) are you requesting?*
How many people are you requesting masks for?
Are you hoping to regularly receive masks from us?*

YesNoUnsure / Maybe
What kind of masks are you requesting?*
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Earloop Green Kid's Surgical Mask Surgical style. 3-ply. Kata brand.
$ Free Quantity



Earloop White KN95Bi-fold style. AccuMed brand. They run small.
$ Free Quantity



Earloop White Kid's KF94Tri-fold/ Boat Style. 4-ply. Blue Tiger brand. They usually fit 4-9 year olds, but may fit younger or older kids.
$ Free Quantity



Strapless Adhesive Yellow N95 - Small Bi-fold + Duckbill style. Acrylic adhesive. They are usually used for haircuts, for MRI or other procedures that don't allow metal/ nose wire, and for dentist appointments (using the nose-only hack). Check out the links at the bottom of this form for 2 videos and a graphic about using an adhesive N95 mask!
$ Free Quantity



Headstrap White 3M Aura N95Tri-fold/ Boat Style. 9205+ version (blue straps). They are meant to fit a lot of different faces.
$ Free Quantity



Headstrap White 3M V-Flex N95 - SmallDuckbill Style. 9105 version. This is the SMALL size, meant for smaller faces (for teens or adults). There is a very limited amount of these masks, so we'd like to reserve these for people who need them (vs. for events)
$ Free Quantity



Headstrap White 3M V-Flex N95 - LargeDuckbill Style. 9105 version. This is the LARGE size, meant for larger faces. There is a very limited amount of these masks, so we'd like to reserve these for people who need them (vs. for events)
$ Free Quantity



Headstrap Light Blue ACI N95 Duckbill Style. Bright blue straps. They are very lightweight and breathable. There is a very limited amount of these masks, so we'd like to reserve these for people who need them (vs. for events)
$ Free Quantity



Headstrap White Kimberly-Clark N95 Duckbill Style. Bright blue straps. They are very lightweight and breathable. They go by a few different names: KleenGuard, KimTech, and Jackson Safety. There is a very limited amount of these masks, so we'd like to reserve these for people who need them (vs. for events)
$ Free Quantity



Total

$0.00
Masks are not one size fits all! We provide demonstrations and education about the different kinds of masks that are available, plus how to use them most effectively. Reach out if you have questions about this or if you want any help figuring out the best mask for you and your situation!
Pick Up or Drop Off?*

Pick Up: W Dauphin St & N Sydenham St [19132]Pick Up: N 52nd & Arch St [19139]Pick Up: S 45th St & Kingsessing Ave [19143]Pick Up: 58th & Chestnut St [19143]Pick Up: 53rd & Pine St [19143]Drop off (answer the next 2 questions too!)
If you need a drop off: please share an address (the address does not have to be your own and can be a storefront, community hub, etc). If the drop off is at a front desk or mailroom, please include any name, apartment/dorm number, etc that might be needed for delivery.
Drop off location
If you need a drop off: are you meeting us there or is it a no-contact drop off? If it's no-contact, is there a mailbox, covered porch, or front desk that we can leave the masks at?
Drop off type
Are there certain days and times that work better for you than others?
Best days and times
Are there any specific child or adult masks you want to see us offer? (mask type, brand, color, etc) Any additional info you'd like to share? Questions / Feedback? What about access needs or security needs?
Adhesive N95 Resources

Graphic - how to put it on, take it off, and how to "seal check"

https://cdn.shopify.com/s/files/1/0373/0187/8917/files/GSF_N_Series_User_Instructions_V_c.pdf

Video (1.5 minutes) - how to put it on, take it off, and how to "seal check"

https://www.youtube.com/watch?v=rIeQg_ZUIX8

Video (2 minutes) - how to do the nose-only dental hack

https://x.com/FindMeABluebird/status/1517896018188197891

(you don't need a Twitter account to watch!)

* If you’re not able to get the mask to stick, you can try washing your face with soap first. You could also try using either micellar water or isopropyl alcohol on your face. All of these things help the mask stick better by removing the oil on your face.

** For the nose-only dental hack, some people find it easier to apply the mask upside down so that the sticker part is on the top.
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Mask Request Form

Adhesive N95 Resources