43rd District Resource/SERVICE REQUEST FORM
Senator Mary Washington has been working in Annapolis with colleagues to pass emergency funding for COVID-19 resources while simultaneously coordinating with people on the ground in the 43rd District to convene a 43rd District Resource Assistance Team with the Baltimore City Delegation. This team is meant to pull together and streamline critical resources to keep you informed, as well as act as a volunteer delivery service for those who may not be able to leave their homes due to being at-risk. Delivery includes only picking up (not ordering) medication, household groceries, food, and any other needs you may have.

The purpose of this form is to provide delivery services for those in the community that do not have the ability to leave their home due to the dangers of COVID-19. Please leave a detailed response in the applicable description box.

After you fill out this Pickup Request Form, we will contact you to go over details and availability. For any further clarification please contact us at 1(800) 291-5457 or 43rddistrictrt@gmail.com

DISCLAIMER: This resource is not for medical advice, but to connect you and loved ones to necessities as well as provide updated information whenever possible. If you need to speak with a medical professional, call your primary care doctor or 2-1-1. If you can't reach 2-1-1, call (410) 685-0525 for the Greater Baltimore Area. You can also visit health.baltimorecity.gov for updates from the Health Department.
Have you used this service before?
Clear selection
For Food Related Needs
Please describe below:
For Medication Related Needs - Pickup ONLY
Please describe below:
Lawn Mowing Services (help). I am a senior over the age 60 or a disabled person who needs my lawn mowed (this service has a 1 week waiting period.)
Clear selection
For Other Pickup Needs
Please describe below:
Contact info
We need this information to proved you with help.
Your name *
Street Address *
What district do you live in?
Clear selection
Neighborhood *
Phone number *
E-mail
Preferred contact method *
Required
Questions and additional comments
Submit
Never submit passwords through Google Forms.
This form was created inside of Mary Washington for Baltimore. Report Abuse