Pilsen Solidarity Network COVID-19 Support Form
If you would like food or other supplies dropped off at your front door, please use this form.

**Donate** www.gofundme.com/f/pilsen-vencera-covid19

**View this form in another language**

Español (Spanish): https://forms.gle/cReuD6vtuBmKmoop9

** Questions, updates or want to get involved? **

pilsensn@gmail.com

We are an all-volunteer grassroots group operating in the Lower West Side (Pilsen/Heart of Chicago).

Let’s take care of each other. By us for us.

We will try to let you know if we can meet your request within 48 hours. We're so glad you've reached out to us for support.
Drawing from the brilliance, love and creativity we have for each other and looking to learn from those showing solidarity globally, including those in Wuhan, China, we aim to cultivate a politics of autonomy, solidarity, and mutual aid within a long-term, multi-generational horizon of decolonial, anti-capitalist, feminist, queer, and disability liberation.

No body is disposable.

Close all prisons, jails, juvies and detention centers now!

(form adapted from Seattle area Mutual Aid Solidarity Network)
Name *
This does not need to be your legal name. Add your pronouns, too, if you want (i.e. she/her/hers, they/them/theirs, he/him/his).
Your answer
How should we contact you? *
Required
What is your phone number?
Please include your area code. Leave this field blank if you do not have a phone number.
Your answer
What is your email address?
Leave this field blank if you do not have an email.
Your answer
How many people are in your household?
Your answer
Dietary Restrictions, Allergies, or Intolerances
Halal, kosher, vegetarian, vegan, allergic to peanuts, lactose intolerant, gluten-free, scent sensitive, etc -- this is important in case we're trying to substitute "our best guess for what you'd like" in place of "something you asked for" that's out of stock.
Grocery List *
Items can be general like "milk," or specific like "a 24-pack of the purple Always brand overnight menstrual pads with wings." We will do our best to match your requests, but if we can't find something specific we may get you a similar substitute. We trust you to know your needs and we are committed to delivery without judgement.
Your answer
Do you need someone to pick up your prescriptions for you? If yes, which pharmacy?
Please either give a phone number/Signal/Facebook messenger option so we can reach you (this option is safer) - OR - include all relevant info here, like your legal name, date of birth, and the names of the medications (Google forms are not secure!).
Your answer
Do you have concerns about your housing situation?
Do you have any other needs or requests?
Your answer
Would you like financial support? *
We can fund up to $50 of supplies per request (while funding lasts) for folks who are quarantined without pay, sick, disabled, elderly, undocumented, queer, Black, Indigenous, and/or people of color.
Delivery Address *
Your answer
What day would you like us to deliver to you? Please give us 48 hours to respond to your request.
We can't guarantee timing, but will do our best.
MM
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DD
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YYYY
Any additional specifications, comments, questions, accessibility needs, or drop off instructions?
Your answer
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