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:
If you have any questions or to learn more about who we are, visit our website at
, call us at 207-370-1581.
Your first name
Your last name
Best way to contact you
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?
Yes, every other day
What type of assistance do you need? Check all that apply.
Canned or easy-to-prepare food donations delivered
Transportation to or from essential appointments or errands
Child care (add details in open response section)
Pet care (add details in open response section)
Virtual assistance navigating or advocating for social or medical services
Do you need food from a food pantry or from a grocery store?
If you would like food from a grocery store, are you able to pay for those groceries?
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?
My medication/s are completely covered by my insurance
My medication/s are partially covered by my insurance, but there is a co-pay. I can cover the co-pay.
I can pay for my medication/s
I need assistance paying for my medication/s
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.
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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This form was created inside of Millinocket Memorial Library.