Vital Villages OR - Support Form
Confidential – For Internal Use Only
We’re here to listen, support, and walk with you. This is a judgment-free space.
Sign in to Google to save your progress. Learn more
Basic Information
Full Name: *
Date of Birth:   *
MM
/
DD
/
YYYY
Phone Number:   *
Email Address:   *
Preferred Method of Contact:   *
Required
Home Address (optional):  
Family Information
How many children do you have? *
Ages of your children:   *
Are you currently parenting alone?   *
Are there any current safety concerns for you or your children?   *
Required
If yes, and you feel safe to share, please briefly explain:  
Support & Needs
What kinds of support would be most helpful right now? (Check all that apply) *
Required
Would you like to be matched with a peer mentor or support circle? *
Your Voice Matters
What’s been feeling heavy or hard lately?   *

Have you already been in touch with a volunteer from Vital Villages OR? If yes, please provide their name.

 *

How did you hear about Vital Villages OR?

*

Anything else you’d like us to know?

 *
Consent & Follow-Up   *
Required
By checking this box, you acknowledge that it will serve as your electronic signature, authorizing and permitting us to proceed accordingly. *
Required
Date: *
MM
/
DD
/
YYYY
REMINDER:
We do our best to match available donations with needs. Someone from our volunteer will follow up with you within 2–3 business days.

We are currently NOT able to help with: 
  • Rent or utility bills  
  • Gas cards  
  • Gift cards or cash assistance  

Thank you for being part of our community.  
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Vital Villages OR.

Does this form look suspicious? Report

Google Forms