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Mask Order Request Form
These are trying times and it is imperative that we all do our part to stay safe and keep each other safe. To that end, I recently purchased a large supply of cloth face masks. I am making these available for those who need masks in the West Valley. Priority will be given to those residing in the communities of Council District 3-Canoga Park, Reseda, Tarzana, Winnetka, and Woodland Hills. Please note, filling out this form does not guarantee a mask. You will receive confirmation from our office when your mask is available.
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First Name *
Last Name *
Street Address (Please include house number, street name, and apartment number) *
City or Neighborhood *
Zip Code *
Email Address (Please input carefully so we can contact you ASAP.) *
Phone Number *
How many people reside in your household? *
I have a limited number of masks available. To reach the most people, I am providing up to 2 per household. Please indicate how many you need. *
Drive thru pick up in Reseda is the only location offered at this time. You will receive an email confirmation date and time for pick up. *
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