Everett Community Aid Network – Needs & Support Form
This form has been created to match people who need support with people or agencies who can provide support in response to COVID-19. Your full responses will only be visible to the Everett CAN group coordinators and will be kept confidential. Your contact information will only be used to coordinate responses to community needs.
After submitting, please check your email for a message from us that includes our full resources listing and our contact information. These resources are updated on a monthly basis. If the emailed listing does not have what you are looking for, please respond to the email with your specific circumstances and request, and we will try our best to connect you with a resource that can help. If there is a need that you think a neighbor could help you with (baby clothes, grocery shopping, etc.), please post on our Facebook page letting the community know what you need. If you know of someone in need and can help coordinate assistance, please feel empowered to post that on our shared page as well!
Facebook Page -
https://www.facebook.com/groups/220072455722934/
* Required
First and Last Name
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Your answer
Phone Number
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Your answer
Email Address
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Your answer
Home Address (please include house/apartment number, street, and city)
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Your answer
I prefer to be contacted by
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Phone Call
Text Message
Email
What is your preferred language?
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English
Spanish
Portuguese
Haitian Creole
Other:
I am currently in need of help with
Delivery of food - I am not able to leave the house
Finding a food pantry
Cleaning supplies
Diapers
Hygiene items
Applying for Food Stamps/SNAP
Applying for unemployment
Paying rent
Paying utilities
Other financial assistance
Assistance with health insurance
Other (please explain below in "other relevant information" question)
If you are currently in need of help, please answer the following
Yes
No
Do you have a child enrolled at an Everett Public School?
Are you a senior citizen, or have a senior citizen living in your home?
Have you or anyone in your home tested positive for COVID-19?
Do you have access to a vehicle?
Yes
No
Do you have a child enrolled at an Everett Public School?
Are you a senior citizen, or have a senior citizen living in your home?
Have you or anyone in your home tested positive for COVID-19?
Do you have access to a vehicle?
Clear selection
I can help neighbors by
Donating financially
Delivering groceries or other supplies
Other (please explain below in "other relevant information" question)
If you are fluent/conversational in languages other than English and can help us translate or interpret for your neighbors, please check here
Español // Spanish
Português // Portuguese
Kreyòl Ayisyen // Haitian Creole
Arabic // اَلْعَرَبِيَّةُ
Tiếng Việt // Vietnamese
Other
Would you like more information on becoming a Neighborhood Point Person (NPP)? This means you’d be the “hub” for weekly food and supply deliveries that you would then take to those in your neighborhood that are in need.
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Yes
No
Maybe
Have you contacted any other agencies or groups for help (for example, Everett 311, churches, other mutual aid groups, etc.)?
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Yes, I got help
Yes, but I didn't get help
No, I have not contacted any other groups
Please explain which groups or resources you have reached out to and your experience:
Your answer
Please add any additional relevant information here
Your answer
How did you hear about us?
Your answer
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