Navajo & Hopi Families COVID-19 Relief Help Request Form

If you would like food or other supplies dropped off at your front door or at your Chapter House, please use this form. Supplies are limited and demand is high, we appreciate your patience as we work to fulfill your request in a timely manner. Please visit our website for other resources in your community: www.navajohopisolidarity.org

We are an all volunteer grassroots indigenous led group operating on the Navajo and Hopi Reservations. We are prioritising the elderly (especially those raising their grandchildren), single parents, and struggling families by helping them buy groceries, water, and health supplies, and by protecting them (and their vulnerable communities) from exposure by engaging volunteers to make the purchases and deliver them to a safe transfer location for the families. Thank you for your grace and patience.

**Information will be kept confidential**

Questions, updates or want to get involved?

FACEBOOK GROUP PAGE: https://www.facebook.com/groups/214813476301051/
EMAIL:
Hopi: hopireliefeffort@gmail.com
Western Agency: westernagencyreliefeffort@gmail.com
Eastern Agency: easternagencyreliefeffort@gmail.com
Chinle Agency: chinleagencyreliefeffort@gmail.com
Fort Defiance Agency: fortdefianceagencyreliefeffort@gmail.com
Northern Agency: northernagencyreliefeffort@gmail.com
PHONE NUMBER: 833-956-1554
WEBSITE: www.navajohopisolidarity.org

DONATE: https://www.gofundme.com/f/navajo-amp-hopi-families-covid19-relief?utm_source=customer&utm_medium=copy_link-tip&utm_campaign=p_cp+share-sheet

VOLUNTEER: https://docs.google.com/forms/d/e/1FAIpQLSdqiiBCpBU-djm9Nj2CLVFolqVZ21yenrIWK47UKVSRF1Mi9w/viewform?vc=0&c=0&w=1

*PLEASE ADVISE- we are not providing dog food. Thank you.


Are you filling this form out on behalf of someone else?
Clear selection
Name of Individual to Receive Services (legal name required) *
Head of Household Name (legal name required) *
Number of people in the household
Legal Name and Age of Everyone in Household *
What's your primary phone number? *
Chapter House or Hopi Village *
Physical Location *
physical address, homestead description, or google plus code acceptable
Does any of the following apply to you or someone in your household? *
Required
If you need other supplies, please select which items you need
*Note: supplies are limited, we will do our best to fill requests
Do you have access to running water in your home? *
Do you have electricity in your home? *
Do you have reliable phone service at your home (including cell phone service)? *
Do you have access to the internet? *
Do you have reliable transportation?
Clear selection
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy