Support for Isolated South Berkeley Neighbors
Who should fill out this form:

IF YOU ARE UNABLE TO LEAVE YOUR HOUSE because of coronavirus/COVID19 and don't have the help you need to get your basic needs met (buy groceries, pick up medications, etc), fill out this form.

IF YOU ARE WORRIED ABOUT A NEIGHBOR who is isolated, lacks support, and could use a check-in on their well being and/or additional help, fill out this form.

IF YOU WANT TO VOLUNTEER to help isolated neighbors, scroll to and answer the last question on this form.


Sign in to Google to save your progress. Learn more
Background Questions
In order to assess community need we would like to ask you some questions about yourself and your personal risk factors.
What is your name?
How old are you?
Check any of the following statements that apply to you...
Supporting Others
Please answer the following questions if there is someone else you are worried about. If these do not apply, skip down to the next section.
What is the person's name who is isolated and needs support?
What is the person's phone number(s)?
What is the person's street address (include apartment number)?
What is the person's email address?
What is the person's preferred language?
Supports and Mutual Aid
Below is a list of possible ways we can support you or someone you know during the coronavirus outbreak.
Would you like support for yourself, someone else, or to volunteer?   *
What do you or the person need?
Clear selection
Is there anything else we need to know?
IF YOU ARE GIVING US INFO FOR SOMEONE ELSE, please share your name, phone number, and email address. We will use your name when we contact the person.
TO VOLUNTEER: If you want to respond to requests for help from isolated neighbors, please give us your name, best phone number, and email address.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms