Request for Aid During COVID-19: Fairfax County

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Please fill out this form if you'd like assistance during the COVID-19 outbreak as we try to limit the spread of the virus. We'd like to help the elderly, those with disabilities, nursing moms, low-income families, or those who speak English as a 2nd language and may have trouble accessing aid.

Name *

Number *

Your Email *

Do you need assistance with English? *

Yes

Your Zip Code *

How would you like to be contacted by one of our volunteers? *

Text Message

Phone Call

Either of these is good.

Required

What kind of aid do you need? *

Grocery shopping/pick up

Pharmacy pick up

Connection to resources available

Transportation help

Childcare services or information

Other:

Required

Submit

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