Bexley Needs Survey
Please fill out this form to to assist us in best matching services and resources to needs.

Our services are available to those who do not have a local support network (family or friends) who are able to assist, and for those who would undergo financial hardship by paying for these services. If you are able to support local businesses (landscapers, dog walkers, grocery delivery services, etc.), please do so.

If you are aware of Bexley residents who are unable to fill out this form independently, please assist them in doing so or encourage them to contact Elizabeth Ellman, Volunteer Coordinator, at eellman@bexley.org or (614) 559-4200. Please contact us for further information or questions. Be sure to press "submit" at the end to ensure your responses are recorded.
First and Last Name *
Please verify the following: *
Required
Email Address
Phone Number *
Best Method of Contact *
May we share pertinent information (phone number, email, address, etc.) with your volunteer match?
Clear selection
Are you currently self-quarantined or otherwise self-contained? *
If you are currently self-quarantined or self-contained, please list the start date.
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DD
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YYYY
If you are currently self-quarantined or self-contained, please list the projected end date (if known).
MM
/
DD
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YYYY
In the space below, please fill out the areas in which you have a need at this current time, giving details (date/time/location of appointment, ages of those needing care, types of supplies needed, location of pharmacy, etc.) below. Please leave any non applicable items blank. Please note that we will make every attempt to connect needs to organizations and volunteers that can fill these needs, but cannot guarantee service.
Please let us know what types of additional supports you may need in the future:
Do you anticipate needing one-time or continual support? Please give as much detail as possible (for example: daily support for animal care, weekly assistance with yard work).
Please share details about your selected needs (dietary restrictions, pharmacy location, supplies needed, etc.).
Please share your address, in the event something is to be delivered to your home.
Please share with us any other of your needs we may be able to provide.
Please let us know anything that may be helpful as we find create a volunteer match, including household information (ages of family members, etc), if applicable.
If these are children living in your household, and feel comfortable doing so, please share with us the school they attend.
Thank you

And a special thanks to Kevin O'Donnell and the Mutual Aid Central Ohio for providing the basis of this questionnaire.
Thank you

And a special thanks to Kevin O'Donnell and the Mutual Aid Central Ohio for providing the basis of this questionnaire.
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