Neighbor In Need (NIN) Request

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NEIGHBORS IN NEED ---> Please fill in this form so that our Healthy Helper Community can triage your specific needs. This group is meant to support those who are especially vulnerable - the elderly, immunosuppressed, quarantined, or people with disabilities - who require tasks of service to maintain their health and wellbeing during the COVID-19 outbreak.

As per the group guidelines + description --> We are here to preform essential logistical tasks for free for those who are unable to leave their homes. It is expected that requested items (groceries, medication etc) are paid for by the NIN upon agreement of service. This is done through Paypal or Venmo. If you don't have either of these, we will be happy to organize a solution with you. We do have a modest stock of essential non-food items, and donated funds, for those who are experiencing struggle due to job loss, disability, health challenges, low income etc.

Answers to these questions are kept fully confidential, and can only be viewed by our Neighborhood Captains (NC) and Admin team. Upon completion of this form - you will be contacted by a Neighborhood Captain (NC) in your area within the timeline you requested.

If you are a DISPATCHER or a NC, please fill in the form with the data you have - and choose 'other' or 'N/A' for the questions you cannot answer.

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Your Name (whomever is filling out the form, dispatcher etc.) *

Neighbor In Need Name (if you are making the request on behalf of another person --your name if the request is for you)

Neighborhood *

Needs Requested *

1. Food Pick-Up - Grocery Store, Food Bank, EBT

2. Pharmacy Pick-up

3. Shopping for Household Essentials - Cleaning supplies, hand soap etc.

4. Shopping for Personal Items - Items needed for health or hygiene reasons

5. Please check on my vulnerable family member or friend!

6. Could I request an item from the "non-food essential item" bank please.

7. Other

Pflichtfrage

If you selected "other" above, please describe your need so that we can best support you (75 character limit)

Preferred Contact Method

Cell Phone Text

Telephone Call

Email Address

Auswahl löschen

Preferred Contact Info (Email and/or Phone Number) *

Urgency *

FB Messenger (please tell us your full FB name below if you would like this option so that we can find you!

Preferred Payment Method (if necessary) *

Are you a Dispatcher? *

Yes

Pflichtfrage

Here is my address:

Senden

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