Keller Williams Pandemic of Love: Request for Assistance Due to COVID-19 Form
Dear Community Member:

First, thank you for your courage. Asking for help takes strength and it's one bravest things you can ever do! We are inspired by you, and we are here to help you!

If your livelihood has been affected and greatly diminished by the COVID-19 pandemic, if you are an hourly wage worker, rely on tips, work in hospitality or events, or anything else - please use this form to let us know what specific ways our community can come together to help you in your time of need.

You do NOT have to be affiliated with or referred by Keller Williams to use this form! No matter where you live, we will partner you up with a family or individual that can help you meet this need.

Please note this is a MANUAL process using volunteers working around the clock to generate the match email to connect you with a patron so you may not hear from us for about 72 hours. Some of you will have more than one patron assigned so you will get MORE than one email. We are trying to make you as whole as possible in the coming month(s) ahead.

This form will remain confidential and your personal information will not be shared with anyone until you are matched up.

This is our time to come together as a community to support each other and to create an outbreak of LOVE over FEAR.

Sending you healing, love and freedom from suffering,

Shelly Tygielski, Pandemic of Love

The Keller Williams Aventura, Coral Springs, Fort Lauderdale, and Bonita Springs Market Centers

PS You can always email Shelly at with any questions or concerns AND if you have a great story to share about your connection, please share it! It gives us all hope in this time of uncertainty.
Email *
First Name *
Last Name *
Age *
Best Phone Number to Reach You (With Area Code) *
Which county do you reside in currently? (If you do not live in one of these Florida counties below WE ARE NATIONAL :-) so please fill out the national form on the home page) *
Which city in do you currently reside in? *
Current Zip Code *
Current Occupation(s)
Current Place(s) of Employment (previous to COVID-19 or currently)
Briefly describe the impact of the pandemic on your income (150 words or less)
Please check off the assistance that would greatly help you at this time (check all that apply): *
If you checked "Other" please explain further.
Please indicate the approximate cost range of the assistance you are requesting. (e.g. "Gas for my car $50, Month of medicine for blood pressure $200, etc.)
Is there anything else about your current situation or circumstance that you would like for me to know or convey to others? (e.g. single parent, kids rely on free lunch in school, etc.)
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy