Family needs for COVID-19
Heal Charlotte has developed a comprehensive survey during the COVID-19 crisis that will allow us to assess your needs. Although we cannot guarantee that every request will be fulfilled, a good faith effort will be made to address food needs, technology and connectivity needs, and stability and safety needs.

Heal Charlotte is partnering with Charlotte Mecklenburg Schools to identify the organizations in your area that can best meet your needs. Please take time to complete the entire survey.

*I give permission for my personal contact information to be shared with other organizations (non-profit, faith community, volunteer groups) in order to meet the various needs listed below. *
Required
Name *
What is your email *
What is your address? *
What is your phone number? *
Please indicate what organization referred you to this form. *
Do you need any immediate supplies? *
If yes to the above question please list the supplies you may need below
How many dependent children live in the household? *
What is your yearly household income? *
Have you recieved your stimilus check? *
Please list child/children's names and ages *
Would you like to have your children signed up for the Heal Charlotte Free Lunch Program or another free lunch program in your area? *
Required
Do you need meals delivered to you because you don’t have transportation or you have medical conditions that prevent you from traveling to pick up meals? *
Would you need assistance with childcare while you are at work (ages 6 and older)? *
What school does your child/children attend? *
Was your child/children provided a Chrome book from school? *
If yes, how many children recieved chromebooks from school. *
Do you need any assistance accessing Health screenings? *
Do you have any seniors 55+ in your house? *
If yes how many seniors do you have in your household? *
Are their any specific services they may need (transportation, pharmacy, health care?) *
Do you have access to technological devices at home, ex: computer, laptop, tablets, iPad, etc.?
Clear selection
Do you have internet access at home?
Clear selection
Have you received updates from Duke Energy and Spectrum about free WIFI and Duke Energy Bills?
Clear selection
If no to the above question, Spectrum will be providing free internet access to families that are not service connected for 60 days. Duke Energy will not be disconnecting energy services during this time. Would you like more information about how to connect with Spectrum or Duke Energy?
Clear selection
If there are any other needs that you may have please list them below.
Are you a resident of a Hotel/Motel for more than 30 days? *
What hotel do you currently reside in?
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