Emergency Hygiene Request

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Please use the form below to request FREE basic hygiene necessities. These necessities include:

Body Wash
Bar Soap
Toothpaste
Deodorant
Laundry pods

These are the only items provided in our Free Emergency Hygiene Kit at this time.

Are you completing this form for yourself/ household or a client?

Name of Agency

Agency Representative Name

Agency Address:

Preferred Method of Contact:

Phone Call

Phone number

Your Name

Address

Do you (or your client) currently live in Baltimore City, Maryland?

Yes

No, but I really need help

I'm not sure

Have you (or your client) previously received hygiene items from Parts of Peace during COVID-19?

Yes

Unsure

Name / Client Name:

How many people live in household?

Has family been affected by COVID-19?

Please check any of the following that apply:

I live alone

Children aged 0-3 live here

Children aged 4-12 live here

Children 13-17 live here

Adults over age 60 live here

A disabled person lives here

Effects of COVID-19, check all that apply:

I am (or your client is) home from work due to COVID-19

I am (or your client is) temporarily unemployed / laid off due to COVID-19

I am (or your client is) permanently unemployed / laid off due to COVID-19

I am (or your client is) home because by children need childcare during COVID-19

I have (or your client has) reduced income because of COVID-19

I am (or your client is) having challenges paying my rent, utilities and other bills

How many children 0-3 live in the household?

How many children 4-17 live in the household?

How many older adults live in the household? (60+)

Benefit Status - Check all that apply:

I was (or your client was) receiving SNAP benefits / food stamps before COVID-19

I was (or your client was) receiving unemployment income before COVID-19

I was (or your client was) receiving temporary cash assistance before COVID-19

I was (or your client was) receiving disability / SSI before COVID-19

I have (or your client has) requested SNAP benefits / food stamps as a result of COVID-19

I have (or your client has) applied for unemployment as a result of COVID-19

I have (or your client has) applied for temporary cash assistance as a result of COVID-19

I have (or your client has) applied for disability / SSI as a result of COVID-19

Check All That Apply

I (client) do not own a vehicle

I (client) don't have access to transportation

I (client) am over 62

I (client) am disabled

I am (client) immunocompromised

I am (or client is) experiencing mental health challenges

English is NOT first language

I'm having challenges finding resources for food and hygiene items

I cannot / client cannot afford all or some of the food and hygiene items that are needed at this time

I am / client is caring for children 13 and under

Household COVID-19 Status

Are there any other ways COVID-19 has created challenges for your family?

We need the following:

Body Wash or Bar Soap

Laundry Pods (enough for 5 loads of Laundry)

Toothpaste

Deodorant

Body Wash or Bar Soap?

Body Wash (1 Full Size)

2 Bar Soaps

Are feminine hygiene items needed?

Yes

How many women in the household require feminine hygiene items?

What types of feminine hygiene items are preferred?

Pads only

Pads & Tampons

Tampons only

Does your household require "free & clear" products (products without scents, etc.)

No, but open to "free & clear products"

Yes, we would like "free & clear products" where possible

Your Contact Information

This section gives us information about where you live and how to contact you for questions and delivery.

Case Manager's should enter client's information here.

Address

City

State

Zip Code

Phone number

How will these items help you or your family?

How did you hear about this program?

If "other" please tell us how you found out about this program

Delivery or Pick-Up

This section informs us about how to get your hygiene items to you.

Would you like pick-up or delivery?

I can pick up items from your office between 12pm - 3pm (5011 Arbutus Ave, Baltimore, MD 21215). Please note that pick-ups are often ready the same or next business day.

Please deliver items to my home. Please note that delivery of hygiene items can take up to 1 week after submitting your hygiene order.

For pick-ups, please note the following:

You will receive an email confirmation that your hygiene order has been submitted.

We may contact you if we have questions about items listed on your hygiene order

We will contact you and let your know your hygiene items are available for pick-up.

You will need to make a pick-up appointment to pick-up hygiene items from our office.

For delivery, please note the following:

Items are delivered by volunteers for FREE who generously devote their time and gas to make sure you have the items you need. Please remember to be kind when speaking with volunteers and Parts of Peace staff.

We will inform you of your delivery day, but cannot always confirm a time of delivery on that day.

All items are provided free of charge at this time due to the generosity of others. Please be mindful that we cannot always be responsive to requests for specific brands/products

This service is currently provided for free due to a generous grant from the Lockhart Vaughan Foundation and other fundraising efforts, however it is costly to provide free full-size hygiene items & free delivery. Please consider making a small donation to keep this effort going. Please note it is NOT required to make a donation to receive hygiene items.

At this time, I cannot make a donation

I will make a donation at pick-up

I will send a cash app donation to $PartsofPeace

I will send a venmo donation to @PartsofPeace

I can make a $1 donation to help with the cost of my items and delivery

I canmake a $2 donation to help with the cost of my items and delivery

I can make a $3 donation to help with the cost of my items and delivery

For further information about delivery dates, delivery times, our operations and more, please like us on Facebook and on Instagram. You may also message us using these social media platforms if you cannot reach us via phone or text due to high call volume.

Do you have any additional questions or concerns?

Let's Stay Connected

In addition to our Free Hygiene items offered during the COVID-19 pandemic, Parts of Peace also operates other programs and community initiatives designed to provide access to basic necessities for all families in Baltimore.

Add me to the email list to learn about more free hygiene items, resources for food, childrens programs and supplies and more!

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