Mask Request Form
If you are a healthcare worker in a hospital, a prison, a nursing home, or a pharmacy in the tri-state New York / New Jersey area, and you need masks or mask covers, please use this form to request home-made masks.

Our volunteers and seamstresses are working tirelessly and around the clock to support our healthcare heroes.
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Email *
First Name *
Last Name *
Facility Type *
What department do you work in? Are you willing to accept these on behalf of your department *
How many headbands are you requesting and who are they for? *
What is your current role at your facility? *
What is your email address? *
What is your phone number? *
What is your preferred way of communication? *
Do you need anything else ? *
No I cannot donate at this time
Yes I would like to help you pay for supplies
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You understand that These are not personal protective Medical equipment.
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