Mutual Aid NYC Request for Support

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

What is this sign up for?

This list is being compiled by the New York Caring Majority to share with groups that are organizing mutual aid and neighborhood pods around COVID-19 in New York. We will only share this list with groups doing mutual aid in New York. We will not use or share the info you provide for any other purpose.

This effort, like many around COVID-19, is in rapid development. We are building our capacity, and responding to ever-changing requests and an ever shifting situations, as quickly as we can.

Email *

What is your age? *

What is your name or what would you like us to call you? *

Please provide a phone number and/or email address so we can contact you to help. *

Are there existing centers, organizations, or networks that you usually rely on for supports or services?

Zip Code where you live

You're welcome to share your full address with us (optional)

Emergency Contact Person (with phone number and/or email or other contact information)

How are you feeling today?

Good

Really Bad

Clear selection

NOTE: If you are feeling ill: Call your regular health care provider for guidance. Do not go to a clinic or hospital without calling ahead. New York City residents without a health care provider or insurance can call NYCHealth + Hospitals at 844-NYC-4NYC. Seek medical attention promptly if your illness is worsening (e.g., you develop difficulty breathing). You should still call ahead, so that providers may prepare for your arrival.

I am seeking assistance with... (Please note: we may not be able to provide all these things. We are trying to gather information about what is needed, and what people are able to offer.)

Information on COVID-19 for myself or people I know

Grocery delivery

Home cooked meals

Transportation for my care providers

Transportation to medical facilities (to avoid public transportation and ride shares)

Medical supplies (list below in OTHER)

Cleaning supplies

1 on 1 Phone Calls / Video Chats / Home Visits / Companionship

Assistance navigating and advocating for services (list services in OTHER)

Personal assistance care

Childcare

Eldercare

Petcare

Concerns about my safety or well-being (you can choose to list details in OTHER)

Other:

Do you live alone?

Yes

Other:

Clear selection

Are you hard of hearing / Deaf and need someone who uses ASL?

Yes

Other:

Clear selection

What languages do you speak?

What language do you read or write?

Do you have reliable transportation? (this is not a requirement)

Yes

Clear selection

Anything else you would you like us to know about you:

Any other comments, questions or concerns?

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Jews For Racial & Economic Justice Community, Inc (JFREJ Community). Report Abuse

Forms