Face Shield Request Form
Our citizen scientists have designed and are manufacturing face shields that we want to get to you! Please fill out the following form to let us know how many you need and how we can get them to you.
Email address *
Number of shields requested *
What is your level of urgency for shields? *
It would be helpful to have more masks
We are out and our lives are in danger.
Contact Info
Contact Name *
Contact Phone *
Ok to receive text messages? *
Required
Facility Information
Name of your facility *
Delivery Address *
Delivery Contact Name *
Delivery Contact Phone *
Delivery Contact Email *
Anything else we should know?
Submit
Never submit passwords through Google Forms.
This form was created inside of ReAllocate, registered 501c3.