Community Face Mask Project – Non Profit Organization Request Form

Community Face Mask Project – Non Profit Organization Request Form
Name of your Agency
Is your organization a 501c3?

Yes No
Agency's Tax ID
Agency's Website
Address of Primary Office

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Name of Person Submitting Request

First Name Last Name
Title
Email
example@example.com
Phone Number
Mission/Key Activities of Requesting Organization
Provide a short description of your agency
What is the nature of your Face Mask Request? Check all that apply. I am seeking cloth face masks to provide to:

Children Served by my Organization Adults Served by my Organization Volunteers Employees
I would like to request __ pediatric reusable/cloth masks for clients
I would like to request __ adult reusable/cloth masks for clients
I would like to request __ adult reusable cloth masks for volunteers (please limit request to total number of current volunteers or fewer)
I would like to request __adult reusable cloth masks foremployees (please limit request to total number of current employees or fewer)
Would you be willing to assist DHC in publicizing the community mask project by sharing opportunities for mask donation and/or mask requests with your networks? *

Yes No
If masks are donated for your agencies use, may we identify your organization as a recipient of the Community Mask Project? *

Yes No
Click here to signal agreement that masks, if received, will be provided to people living or working in DuPage County. *

I Agree
Click here to signal agreement that your agency will provide masks, if received, at no cost to recipients. *

I Agree
Click here to signal agreement that your agency would be wiling to participate in social media outreach publicizing this community effort. *

I Agree
Should be Empty: