COVID-19 Peninsula Community Immediate Needs Survey - By Peninsula Union School District
This order form is for anyone who lives in Samoa, "Fintown," Fairhaven, or South Manila who may benefit from assistance during the COVID-19 pandemic.

If you need food or supplies, we want to help you shelter in place by bringing you what you need. This is a service our school is offering, free of charge, for as long as we are able. Fill out the below form to get daily food delivery, and/or to receive a delivery of household necessities.

This is paid for by generous donations from local community members. If you, or someone you know, wants to support our continuing this service, call our office to find out how to become a patron (707)443-2731.

Name of Person filling this out. *
Your answer
If different, what's the name of the person/people this is being filled out for?
Your answer
Do you have anyone over 60 years old, under 18 years old, or anyone with underlying medical conditions living in your home on the peninsula?
If yes, would you like for us to deliver meals to you on weekdays around 10AM?
If yes to meal deliveries, how many people would you like meal deliveries for each meal?
Please type the best phone number for reaching you in the coming weeks.
Your answer
Please type in your email address here.
Your answer
Are you currently experiencing cold or flu like symptoms? If so, check all that apply *
Required
Would you like for us to deliver any basic necessities? Check all boxes that apply
If you know of someone in your neighborhood over 60 or medically vulnerable to COVID-19 who you would like us to reach out to, what is their name and phone number (if known)? Or, you are welcome to fill out this survey with their permission on their behalf.
Your answer
If you would like meal or other deliveries, what is the address you would like them delivered?
Your answer
Does a student who attends Peninsula Union School live with you? *
If YES, what is your student’s name?
Your answer
Do you have any questions or comments about COVID-19 and the measures being taken to prevent its spread?
Your answer
We are grateful for the opportunity to support our community through these deliveries. In order to keep our staff as safe as possible while they are delivering resources, please observe at least a 6 food distance from anyone working our delivery truck. Thank you for supporting our staying healthy so we may continue to support our community through this shelter in place. Thank you!
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