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Cloth Mask Request (Boulder City)
If you are requesting masks please fill out this form. Our priority as a group is to serve those who are on the front lines first.
You will be contacted via email. Please provide an address you check regularly.
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Cell phone number (we will text not call)
*
Your answer
Do you live in Boulder City?
*
Yes
No
I work in Boulder City
What are your cross streets?
Your answer
Are you in an essential role for work?
*
Yes, healthcare (nurse, doctor, CNA, etc,)
Yes, first responder (police, fire, EMT, etc.)
Yes, retail essential (grocery, hardware, food, etc.)
No
If you are not working at this time, are you or someone in your household considered high risk?
Yes
No
Clear selection
How many masks are you requesting?
*
Choose
1
2
3
4
5
More
If you answered “more”: How many masks do you need? If they are for a business or organization please state your affiliation.
Your answer
Is there a style of mask you would prefer?
*
Option 1 - fitted mask (Craft Passion pattern)
Option 2 - pleated surgical style mask
No preference
Filter pocket please
Required
Anything else we need to know? Age, size, gender of persons requested for
Your answer
Submit
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