REQUESTS: Mobilize Katahdin
Please fill out this form to REQUEST support during the COVID-19 crisis. Your information is confidential and will only be shared with key organizers.

If you would like to OFFER aid, fill out this form instead: https://forms.gle/ZA9cKkr7q83GNRGYA

If you have any questions or to learn more about who we are, visit our website at www.mobilizekatahdin.org, call us at 207-370-1581.
Your first name *
Your last name *
Best way to contact you *
Contact information *
Please only provide an email address if you regularly check it. If you would like to be contacted over Facebook Messenger, include your full name as it appears on Facebook.
Number of people in your household
Do you have a support network that is checking in on you frequently? *
If you responded "no" to the previous question, would you like someone to check in on you during the COVID-19 crisis?
Clear selection
What type of assistance do you need? Check all that apply. *
Required
Do you need food from a food pantry or from a grocery store?
Clear selection
If you would like food from a grocery store, are you able to pay for those groceries?
Clear selection
Are there any specific food items you need?
We cannot guarantee that specific food requests will be met, but we will do our best.
If you requested food, does your household have any dietary restrictions?
Specific supplies requests (diapers, toilet paper, soap, etc)
Do you need medication/s picked up? If yes, please include your pharmacy, your full name as it appears on your prescription, and your date of birth.
Name and date of birth are required in order for a prescription to be picked up. The information will be stored securely and only viewed by necessary volunteers and organizers.
If you need medication/s picked up, do you have a means to pay for them?
Clear selection
If you need items delivered, what is your address?
Please include details like which door should be used and whether there is a covered porch where supplies can be dropped off.
Do you have any other requests?
What time and date do you need assistance by? Please allow 48 hours for us to meet your request. *
We can't guarantee timing, but we will do our best.
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Do you know of anybody that may need help that we should check in on? If yes, what is their name and contact information?
Any other questions, comments, accessibility needs, or drop off instructions?
If you requested child care or pet care, please include details about number of children, age of children, and number/types of pets.
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