Mask Bloc NOVA Request Form

Mask Bloc NOVA Request Form

Please use this form to request masks and tests from Mask Bloc NOVA!
PLEASE READ: Please keep in mind that we are a volunteer-run, majority-disabled organization and we rely on mask donations, so our stock and timelines can be a bit unpredictable. We will try our best to accommodate your request but cannot guarantee specific brands or delivery times.

After 3 check ins, your order will be closed and you must resubmit a new Jotform request. Your Jotform will be deleted after your order has been completed to protect any sensitive information.

Geographical range we serve: McLean, Falls Church, Manassas, Woodbridge, Tysons, Fairfax, Merrifield, Oakton, Sterling, Herndon, Reston, Vienna, and Great Falls. (Includes areas loosely in between two of these). If you're outside this range, you can still fill out the form- we may still be able to help,or direct you to another nearby org that can do so.
Completed?
Assigned? Comment Name
What name would you like us to call you? *No last name needed**
Would you like any covid tests?*
If you'd like tests, how many? Max is 4 (2 boxes)
No adult masks at this timeHeadstraps (N95)Earloops (KN95 or KF94)Trifold/Boatshape (can be N95 or KF94)Bifold (N95, KN95, or KF94)Duckbill (N95)Adhesive (ReadiMask- strapless & MRI safe)Cup (Honeywell N95, are also MRI safe)
No child masks at this timeTrifold/Boat Shape, earloops (KF94)Bifold, earloops (KF94)
WhiteMint greenNavy blueChristmas patternNo preference!
Note: We will do our best to supply you with your requested mask type, but we may not always have the ability to due to stock fluctuations. When someone reaches out to schedule mask delivery/meet-up, you will be informed of the mask type you'll be receiving, and have an opportunity to decline if it's not the type you had wanted. Please leave specific color requests or brand requests at the end of the form.
Around how many masks would you like? (N/A if just getting tests)*
How many people total are in your household? (N/A if just getting tests. Our limit is 20-30 masks per person depending on current stock levels.)*
Phone: TextPhone: CallEmail
If you choose email, your messsage will come from maskblocnova@protonmail.com. Please be sure to check your spam or junk folder, as sometimes our uncommon domain gets flagged as spam.
What is the phone number or email address we can contact you at?*
Please re-type the above phone number/email address to confirm.*
What area of NOVA are you located in (ex. Tysons, Fairfax, Vienna, Reston, etc.)*
Delivery at my place of residenceMeet-up with a bloc member in a public location (park, library, etc)Scheduled pick-up window (see next question)
If you are interested in a home delivery, please enter your address and any important parking details for your delivery driver.
Tysons Pimmit Regional Library parking lotCity of Fairfax Regional Library parking lotManassas Park Library parking lotOther
YesNo
The earliest we can guarantee filling orders is 2 weeks after you submit this form, as we are a volunteer-run, majority disabled organization. If there is a need more urgent than that, please leave a note in the last question and we'll do our best to work with you.
What date do you need masks/tests by?*

MonthDayYear
Is there anything else you'd like us to know?
Should be Empty: