Mask Request Form — Mask Bloc RVA

Fill out this form to request free masks (and other mask supplies and COVID tests).

If you have requested supplies through this form before but need more, please do not hesitate to fill it out again!

Masks can be reworn, but they should be replaced if you are not getting a good seal, if the head straps or ear loops are loose, if the mask is dirty/soiled, or if you experience increased breathing resistance while wearing it.

Check out our LinkTree for additional COVID information and resources. Feel free to contact us via email at maskblocrva@protonmail.com if you have any questions, comments, or concerns! :)

Please note that all sensitive information contained in this form will be promptly deleted after your request is fulfilled.

Name and Pronouns

You can leave this blank or use a nickname if you are not comfortable with sharing your name!

EmailPhone - text

Enter the email address or phone number we should use to contact you.*

Please ensure this is correct, as it is our only way to contact you!

Yes (needed in the next few days)No (needed in 1-2 weeks)

Preferred Mask Type(s): Select the type(s) of masks you prefer from the options below. If you are unsure of the best mask for you, we recommend choosing the variety pack to test out a few different masks so you can find one that provides a good fit.

DISCLAIMER REGARDING BLOX DUCKBILL N95s: This mask may develop small holes, which can allow unfiltered air into the mask. Please check out this post for more details on this issue!

3M Aura 9205+ N95 (Head straps | Trifold/Boat style | White | Medium/Large fit)
Honeywell DC300 N95 (Head straps | Cup style | White | Medium/Large fit)
Blox N95 (Head straps | Duckbill style | White | Small fit)
Kind KN95 (Ear loops | Trifold/Boat style | White | Medium fit)
WellBefore KN95 (Ear loops | Bifold style | Denim blue | Toddler/XXS fit)
"Blue" KF94 (Ear loops | Trifold/Boat style | Black | Child/XS fit)
"Blue" KF94 (Ear loops | Trifold/Boat style | White | Child/XS fit)
Variety Pack (Assortment of masks of different styles | Contents will vary depending on stock)

YesNo

How many masks do you need?

We provide a minimum of 5-10 of each mask type per request.

Number of SIP Valves Needed:

SIP valves allow you to hydrate without removing your mask. Please indicate how many SIP valves you need. We currently limit these to 2 per person (per request) due to limited stock. These are reusable and can be reinstalled up to 10 times on different masks. They should be replaced after 10 installs or after 30 days of use.

Number of Ear Savers Needed

Ear savers reduce ear strain when wearing masks with ear loops. We currently limit these to 2 per person (per request) due to limited stock. These are reusable. The time between each replacement will vary depending on usage.

Number of COVID Tests Needed?

We provide at least 10 COVID tests per request. We have plenty and are happy to provide more! Some COVID tests may be expired, but they are still helpful. Rapid test accuracy is unfortunately poor regardless, so testing multiple times over several days is recommended.

Drop offMeet-up in a public location

Our designated zone is outlined in red on the map below. We are currently only able to accept drop off requests within the zone. If you are outside of the zone, we can currently only offer meet-up at a location within the zone. (We hope to change this in the future, but we sincerely appreciate your understanding.)

Bloc members will always wear a mask while fulfilling your request!

Drop Off Requests: Please provide the drop off address, including street address, city, state, and zip code.

If the drop off location is at an apartment, hotel, or secure building, please include the apartment/room number, entry code, or any other important information.

Meet-Up Requests: You can propose a potential meet-up time and location below.

Accessibility Needs: If you have any accessibility needs (e.g., due to allergies, limited mobility, etc.) pertaining to your request, please let us know, and we will do our absolute best to accommodate them. We will reach out to you if further clarification is needed.

Requests, Questions, or Comments? Let us know below! :)