Request for Donations
Project C.U.R.E. is committed to helping those in need. Please request supplies only if there is an imminent shortage of supplies and/or equipment.
Facility Name *
Facility Location *
Type of facility *
Contact Name *
Contact Phone Number (Primary) *
Contact Phone Number (Secondary) *
Contact Email *
Which is your closest Project C.U.R.E. Distribution Center? *
Able to Pick-Up from the closet Project C.U.R.E. Distribution Center? *
Number of Providers? *
Number of EMTs? *
Number of First Responders? *
How many days of supplies do you currently have? *
Patients or Contacts / Day *
Top Priorities (select 2) *
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy