I am requesting assistance
We, Clinton County residents, always rally for each other in good times, as well as in bad.
In order to help ensure individuals who are more at risk of developing serious complications from Covid-19 can still meet their basic needs, Neighbors for Neighbors is offering a matching service between individuals who are high-risk and those who are low-risk. For the purposes of this form, individuals who are considered high-risk include those who are 60 years of age and older, people who are immunocompromised and/or people who are experiencing homelessness or economic hardship.
Once a match is made you and your match can coordinate the delivery of essential supplies, like food, toiletries, and prescriptions. You and your match can also help one another feel less isolated by checking-in on the phone or by other electronic means. We will match you with someone in your area as soon as a volunteer becomes available, there is no guarantee of a match and/or financial assistance. We are handling the most urgent requests first.
This is a volunteer effort, run by fellow community members. While there is no guarantee that the needs expressed in this survey can be met, individuals and organizations across Clinton County are doing their best to respond to the challenges of the COVID-19 pandemic.
If your answers change after you’ve completed this survey, please email us directly at
or call/text 937-400-3220 to update your answers.
Email (if you do not have one, write N/A)
Can you receive text messages at the above number?
Where are you located (choose nearest location)?
If you live in Wilmington, on what street do you live? Please include the street direction (for example W Locust St). This will ensure we connect you with a neighbor in your neighborhood.
What do you need assistance with?
Help running errands out of the house (picking up groceries, prescriptions, walking dog, etc.)
Someone to check-in on me and provide some social connection (phone check-ins, text messages, etc.)
Support accessing resources (low-cost food resources, unemployment insurance, etc.)
Please feel free to provide more information on what you need assistance with. If you are completing this form for someone else, please note that here, as well as their contact information.
Do you require financial assistance? Note: Neighbors for Neighbors is a small community response matching neighbors to neighbors. There are a limited number of neighbors who can help with financial needs. We do NOT provide direct aid and cannot guarantee your need will be met.
Do you want to be paired with someone who speaks a language other than English? If so, please specify the language below.
No, English is fine
Do you agree to have your contact information (phone or email only, your address will not be given out) shared with one individual who will serve as your buddy?
Waiver: By selecting "I agree" below, I agree that I would like to be contacted by Neighbors for Neighbors to receive a match and/or be contacted by my match directly. By completing the sign up form to be matched to receive or provide voluntary services, you agree that you accept all risk and responsibility including any injury or harms that may result from providing or receiving services, and further hold any facilitator associated with Neighbors to Neighbors harmless. We are not healthcare professionals, if you need medical advice, please call your physician or 911.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service