Portland area COVID-19 "Request Support" Form
Please use this form if you would like food or other supplies delivered to you.
We are prioritizing folks who are sick, unhoused, disabled, quarantined without pay, elderly, undocumented, queer, refugees and immigrants, Black, Indigenous, People of Color, trans, and queer, including those displaced from Portland to the nearby areas. Thank you for your patience and grace.


We are an all-volunteer grassroots network operating in the territories of the many tribes who have made their homes near the confluence of the Willamette and Columbia Rivers, including Multnomah, Wasco, Cowlitz, Kathlamet, Clackamas, Bands of Chinook, Tualatin, Kalapuya, Molalla. This is a volunteer run effort, and we are utilizing the technology that is easiest and fastest for us. We cannot make guarantees regarding the security of your personal information, and as such you should be judicious about what you share. Any information passed through is at your own risk. We also cannot guarantee response to all requests.

Questions, comments, and updates can be found at:
Facebook: https://www.facebook.com/pdxcovid19mutualaid
Instagram: @pdxcovid19mutualaid
Email: pdxcovid19mutualaid@gmail.com

If you're looking to Offer Support, that form is found at this link: https://forms.gle/jDQUhHuXg8wSXDEq6

En Español: https://forms.gle/Zy9fsm3eNZCBuhDJ7

Let’s take care of each other. By us for us.
እርስ በርሳችን እንከባከብ። በኛ ለኛ።
Vamos a cuidarnos unes a otres. Por nosotres, para nosotres.
守望相助。

Name *
This does not need to be your legal name. Add your pronouns, too, if you want!
[Image is a red name tag that says "Hello my name is" with nothing written in the blank space.]
[Image is a red name tag that says "Hello my name is" with nothing written in the blank space.]
Your answer
How should we contact you? *
Phone numbers for SMS Text is the easiest way for use to reach you. Please include your phone number, email, and/or Facebook messenger -- you can give several options if you'd like.
[Image is a sketch of a smartphone open to a home page with many apps.]
[Image is a sketch of a smartphone open to a home page with many apps.]
Your answer
Please help us be equitable in helping the community. Choosing less dire doesn't mean we won't get to you. We are trusting you to self-identify the urgency of your need using the examples in this scale: *
Dietary Restrictions, Allergies, or Intolerances *
Halal, kosher, vegetarian, vegan, allergic to peanuts, lactose intolerant, gluten-free, scent sensitive, etc -- this is important in case we're trying to substitute "our best guess for what you'd like" in place of "something you asked for" that's out of stock.
[Image is "Mr. Yuk," a disgusted looking green emoji. The emoji is surrounded by a thick black outline, which has the words "Yuk!" and "Stay away!" written on it in all caps.]
[Image is "Mr. Yuk," a disgusted looking green emoji. The emoji is surrounded by a thick black outline, which has the words "Yuk!" and "Stay away!" written on it in all caps.]
Your answer
What types of food do you want? *
Required
Are you interested in a food box from Oregon Food Bank? *
Box will include 1-2 weeks of produce + non-perishable foods.
Grocery List *
Items can be general like "milk," or specific like "a 24-pack of the purple Always brand overnight menstrual pads with wings." We will do our best to match your requests, but if we can't find something specific we may get you a similar substitute. We trust you to know your needs and we are committed to delivery without judgement.
[Image is a person with very curly brown hair, medium tone skin, a pink jacket, a yellow purse, and blue jeans pushing a grocery cart full of groceries: many bottles and bags of different sizes and colors.]
[Image is a person with very curly brown hair, medium tone skin, a pink jacket, a yellow purse, and blue jeans pushing a grocery cart full of groceries: many bottles and bags of different sizes and colors.]
Your answer
Do you need someone to pick up your prescriptions for you? If yes, which pharmacy?
Please either give a phone number/Signal/Facebook messenger option so we can reach you (this option is safer) - OR - include all relevant info here, like your legal name, date of birth, and the names of the medications (Google forms are not secure!).
[Image is an orange pill bottle with a white lid and a sticker that says "Rx" in blue, illustrated to look as if there are more lines of text. The background is a teal circle.]
[Image is an orange pill bottle with a white lid and a sticker that says "Rx" in blue, illustrated to look as if there are more lines of text. The background is a teal circle.]
Your answer
Do you have any other needs or requests?
[Image is the outline of two open hands, palms up, with a red heart shape in each palm.]
[Image is the outline of two open hands, palms up, with a red heart shape in each palm.]
Your answer
Do you need help covering the cost? *
We can fund up to $50 of supplies per request (while funding lasts) for folks who are quarantined without pay, sick, disabled, elderly, undocumented, queer, Black, Indigenous, and/or people of color.
[Image is a drawing of a light skinned hand grabbing six green bills.]
[Image is a drawing of a light skinned hand grabbing six green bills.]
Delivery address *
[Image is a light orange cartoon house with two blue windows, a brown door, a red roof, and red heart-shaped smoke coming out of the orange chimney.]
[Image is a light orange cartoon house with two blue windows, a brown door, a red roof, and red heart-shaped smoke coming out of the orange chimney.]
Your answer
What neighborhood is this in? *
Captionless Image
What day and time do you need things by? *
We can't guarantee timing, but will do our best.
[Image is a cartoon of a blue clock and a red calendar on yellow background.]
[Image is a cartoon of a blue clock and a red calendar on yellow background.]
MM
/
DD
/
YYYY
Time
:
Any additional specifications, comments, questions, accessibility needs, or drop off instructions?
Your answer
How many people are in your household? *
[Image is a drawing of two adults holding a swaddled baby and embracing. One adult has long flowing black hair, a red shirt and pink pants. The other adult is wearing a purple dress and has black hair in a bun. They are both smiling and blushing. The background is light pink.]
[Image is a drawing of two adults holding a swaddled baby and embracing. One adult has long flowing black hair, a red shirt and pink pants. The other adult is wearing a purple dress and has black hair in a bun. They are both smiling and blushing. The background is light pink.]
Your answer
Demographics: If you wish to share your demographics, it will help us know whether we are meeting our goals of equitable distribution. You may let us know if you identify as:
We are doing our best to answer requests as quickly as possible. As the situation develops we are ramping up our dispatch system but may be unable to keep up with needs. Thank you for your patience.
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