Free Mask Request Form
To help combat the mask shortage we’re currently experiencing, a network of volunteers has formed to sew homemade masks. Resilience Dayton, Dayton Sewing Collaborative, YPR Columbus, Mutual Aid Dayton/Miami Valley, Harm Reduction Ohio, Black Rose Collective, and others are collaborating on this effort. Any hospital, nursing home, senior housing facility, homeless shelter, clinic, doctor’s office, home care service, jail, group home, volunteer organization or anyone working with vulnerable populations may request homemade masks. We will distribute masks as they are available. We are working out of Dayton, OH but if you need masks and see this form, fill it out and we’ll either handle your request ourselves or get your information to a group in your area.
Please tell us about your organization and your needs. Someone will contact you soon to verify your needs and make arrangements to get you a mask.
Your Name and basic contact information (Phone number or email address)
Name of Organization
City and State of Organization
Name of manager or other point of contact in organization and their contact information (phone number or email address)
What type of Organization needs mask?
Nursing Home/ Assisted Living Facility
Home Healthcare Service
Drug Treatment or Mental Health Facility
How many masks do you need?
Do you have any specifications for pattern or materials? Please include links or you may provide these when we follow up with you.
Do you need other equipment such as face shields, hats or gowns?
We’re looking for a local facility with an autoclave, UV sterilization or other sanitizing process so we won’t have to mail them. Can you help us with sanitizing and disinfecting these items before we send them out?
Would you like to volunteer or make a donation to help with this project?
Send me a copy of my responses.
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