INTEREST FORM: At-Home Rapid Test Kit Distribution Program

For NYC-based/serving nonprofit/501c3, community-based and faith-based organizations:

Every week, we enroll additional NYC-based organizations. We are especially interested in organizations that serve high-needs neighborhoods, such as the neighborhoods identified by the Taskforce on Racial Inclusion and Equity*, those that lack access to testing options, and/or any organizations that:

- have demonstrated commitment to COVID prevention and/or public health
- have demonstrated capacity to reach at least hundreds of New York City residents
- are prepared to sign legal agreement (MOU)
- are prepared to complete basic reporting of distributions
- are prepared to pick up monthly allocations
- are prepared to store and distribute kits safely, including monitoring expiration dates

(*TRIE neighborhoods: https://www1.nyc.gov/site/trie/about/neighborhoods.page)  

Only eligible organizations will be contacted to enroll. 

INELIGIBLE groups include: for-profit businesses, private medical practices, schools (including PTAs/PAs), political campaigns, elected officials, and others.
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Organization Name *
Organization's website:
Org Primary Street Address *
Borough *
What 3 neighborhoods do you primarily serve in your borough? *
Primary Contact Full Name *
Primary Contact Email *
Primary Contact Phone *
Please list the NYC zip codes you serve primarily *
Please list the top 3 languages you deliver services in. *
Please provide a brief description of your organization.
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