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Pickup location: 3824 east berry st. fort worth, tx. 76105
BarbaraCares - CARE2FIGHT HEALTH INITiATIVE COVID-19 OUTREACH
PLEASE COMPLETE
ENTIRE
FORM BELOW
*
Indicates required field
Your Details
*
Individual
Name
*
First
Last
Email
*
Birthdate MM/DD/YYYY
*
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Are You A Resident Of Tarrant County?
*
Yes
No
Are You A Resident Of Fort Worth?
*
Yes
No
Select Your Pick Up Day
*
Saturday March 13th (12Noon - 2PM)
Saturday April 17th (12Noon - 2PM)
Name of Person Picking Up Items (must present ID)
*
Number of Individuals In Household?
*
Have You Applied Before?
*
Yes
No
Demographic Represented (select all that applies)
*
Breast Cancer Patient(s)
Cancer Patient(s)
Heart / Lung Disease
Diabetes
Respiratory Condition
Immune Condition
At-Risk Age Group
Caregiver(s)
Race / Ethnicity
*
Caucasian
African American/Black
Hispanic/Latino
Asian
Middle Eastern
Pacific Islander
Native American/Alaskan
Other
PPE Requested
Select to make your selection(s).
Please be advised all items requested are only available while supplies last. While we are not able to guarantee quantities or inventory, we will certainly work to accommodate each request and try to fulfill them as best we can until inventory runs out. In our efforts to ensure residents are adequately supplied, please only request what you or your organization is currently in need of. Thanks for your cooperation.
COVID-19 Care Packages Include Any Combination Of The Following: Hand Sanitizers, Disinfecting Hand Wipes, Disposable Gloves, Full Face Shields and Masks (while supplies last)
*
Click To Approve
Have You Been Tested For COVID-19?
*
Yes
No
Have You or Someone You Know Tested Positive For COVID-19?
*
Yes
No
As the need for PPE fluctuates with the rise and fall of COVID-19 cases, the ability of the BarbaraCares foundation to acquire and distribute these materials also varies. It is a part of our mission to provide PPE to help prevent the spread of COVID-19 FOR community members at-risk. BarbaraCares has implemented this online screening request form to facilitate disbursing items from the foundation so we can better serve our clients and make sure we give priority to high-risk members.
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I agree to receiving marketing and promotional materials
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BarbaraCares
About
Barbara's Story
Diversity & Inclusivity Statement
Sign Up
Financials
Online Application
Community Impact
Community Impact 2019
Community Impact 2020
Community Impact 2021
Community Impact 2022
Community Impact 2023
Community Impact 2024
The Board
Advice from the Vice
Employee Portal
Intern Portal
Board Portal
Board Application
Online Giving
Sponsorship
Donate A Mammogram
Online Giving
5 For Life!
Events
Mobile Mammogram Health
March For Mammograms
HealthFair - Care2Fight
>
Healthfair
Contact
Volunteer
Sign Up
News Room
Health Portal
Support Us