PYM Mutual Aid Exchange Application
Please answer the following questions to the best of your ability.
Sign in to Google to save your progress. Learn more
Email *
Your full name. *
Who referred you to the PYM Mutual Aid Exchange?
What current Mutual Aid/ volunteer work are you doing that you would like to receive funds for?
Primary Phone Number
Full Home Address
I am:
How urgent is this need? If you have other needs that might be served through this committee, please describe in detail below. *
Have you reached out to your local monthly meeting, or any other organization for financial assistance? If so, what were they able to cover? *
Are you currently employed? *
Have you signed up for any government assistance? Unemployment, Food Stamps, etc. Were you able to receive the requested services? *
In return for a financial gift, would you willing, be able to perform 20 hours/month of service to support your local community? Please note that a report written by the group will be requested as well upon completion of the project. *
12. Do you have a current health insurance policy? *
13. Is there is a particular service that you would prefer giving (such as organizing work, active work outside, or tech training)? Note: It is NOT a requirement to offer service as a part of this. We just hope to spread the network as wide as we can. We will be requiring that those involved in the higher risk/outdoor activities have active health insurance.
14. Are you aware of Elders, or anyone else in your community that is in need and could benefit from this type of service and support?
Clear selection
15. Do you have any questions or additional ideas you would like to see come through this project?
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy