Delivery aid for the self-isolating (COVID-19)
This form is for high-risk individuals requesting the home delivery of groceries, over the counter medication and basic household supplies. We are unable to deliver prescription medications. Most pharmacies are currently offering free delivery (CVS, Walgreens, etc).

All volunteers are required to practice healthy sanitation, confirm safe temperature before collecting items and use gloves to bag any open foods (i.e. produce).

Volunteers are using personal funds to purchase items and will need to be reimbursed by check or cash upon delivery.

In an effort to keep you safe, do not have contact with the volunteer delivering items. Volunteers will call you after they have purchased items to inform you of the total. After you are informed of the total, leave cash or check made out to the volunteer in a disclosed location (under doormat, in mail box, etc). The volunteer will collect the money and leave items on your door step.


For more information contact Kirk at kirk@southlands.net
First Name *
Your answer
Last Name *
Your answer
Phone Number *
Your answer
Home Address (delivery location) *
Your answer
I am requesting the delivery of... *
Required
Write a detailed list of item's and quantities requested (example: a dozen eggs, block of cheddar cheese, gallon of milk, small dish soap etc.) *
Your answer
Requested delivery date
MM
/
DD
/
YYYY
Special instructions for delivery (gate code, side entrance, dog etc.)
Your answer
Submit
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