Robinson Volunteer Fire Dept. COVID-19 Community Assistance Program
Please complete this form for yourself or on behalf of a family member (with their consent) in Robinson, TX to be checked on during the COVID-19 pandemic, or if they need physical assistance acquiring necessities such as medication or groceries. RVFD does not have the resources to purchase any items for individuals, but will work with individuals to have items paid for at the individuals expense. There is no fee associated with RVFD's services to the community. Robinson Volunteer Fire Department cannot provide face masks, hand sanitizer or any other personal protection equipment to citizens at this time unless their are readily available at a store at the individuals expense.
Your honest responses below will help us prepare to make contact with you. If you have signs or symptoms, we will still assist you, but want to take necessary precautionary measures before making direct contact with you.
All responses are confidential and only shared with essential Robinson Volunteer Fire Department and medical personnel who will be making contact with the individual. This information will only be used during the COVID-19 time and is subject to change based on the availability of our volunteers and call volume within the city.
First & Last Name
Date of Birth
Please select any of the following symptoms you have experienced in the past 14 days (select all that apply):
Fever (Above 100°)
Shortness of Breath / Difficulty Breathing
Are you over 60, pregnant, or have a chronic lung condition, heart disease, diabetes, or on an immune suppressive medication?
If Yes, please explain:
Are you currently having difficulty breathing, unable to eat or drink, or too weak to care for yourself?
Please select any community resources you are currently receiving (select all that apply and list other resources in "other"):
Meals on Wheels
Home Health Care
What are your immediate needs? (RVFD will contact you for additional information if needed.) Select all that apply.
General Welfare Checks (Daily)
Pick Up Medication
Pick Up Groceries
Emergency Contact Name & Phone Number
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