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. After your order has been completed, your information will be deleted.

    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.

  • What type(s) of ADULT mask would you like? (see below for example images)*
  • What type(s) of CHILD mask would you like? (see below for example images)*
  • If ordering child-sized masks, what is your color/pattern 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.

  • How should we contact you?*

  • 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.

  • How would you prefer to receive your masks/tests? (Select all that you could do)*
  • If you are interested and able to meet up in a public place, please select one or more locations that would work for you.
  • Is someone in your household currently infected with COVID-19, or experiencing symptoms of illness?*

  • 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?*
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