Grocery & Medication Delivery Service for Homebound Individuals
We at AHOPE would like to extend our help to those who are homebound due to the spread of COVID-19. Homebound individuals are those who are at high risk for COVID-19, including older individuals (over age 60), people who are sick or disabled.
If you are homebound due to COVID 19 and need delivery of your groceries or medication, we can help. Please complete the form below and explain why you are homebound and how you will pay for your groceries/medications, and one of our volunteers will be in touch with you. Alternatively, you can call or text us at (401)-484-1819.
Please note: requests are expected to be fulfilled within 24-48 hours, usually sooner. Our volunteers cannot provide any medical advice or help. All delivery volunteers are expected to complete a BCI background check prior to making deliveries.
This information will not be shared with any individual or group outside of the AHOPE team.
* Required
Your first and last name
*
Your answer
Your phone number
*
Your answer
Your age
*
Your answer
Your home address
*
Your answer
How did you get your medicine/groceries before?
*
Your answer
How will you pay the driver?
*
Your answer
Do you need medication picked up?
*
Yes
No
Please select the items you would like:
*
Bananas (3 lbs bag) $1.40
Black Bean (Can) - $0.91
Cereal Cheerios 40.7 oz - $2.90
Cereal Frosted Flakes 24 oz - $3.64
Chic Peas (Can) - $0.85
Eggs ( 1 dozen ) - $2.40
Jasmine Rice (2 lbs) - $3.77
Jelly (18 oz) - $2.84
Lentils (1 lb) - $0.76
Milk (1 gallon) - $2.85
Pasta - $1.20
Pasta Sauce $1.50
Peanut Butter (18 oz) Walmart Brand - $1.58
Peanut Buttter (28 oz) Jiff - $3.84
Sugar Free Jelly (12 oz) - $2.78
Tomato Paste - $0.52
Tuna - $1.25
White Bread $2.40
Other:
Required
Please provide us with a list of any food or medication allergies you may have.
Your answer
How would you like us to contact you?
*
Phone
Text
Next
Page 1 of 3
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms