Request for Assistance Due to COVID-19
Dear Community Members:

Thank you for your courage, asking for help takes courage.

If the livelihood, health or educational security of your family or community has been greatly diminished by the COVID-19 pandemic, please use this form to let us know the specific ways in which our community can come together to assist you in your time of need.

We will partner you up with a family or individual that can help you meet this need.

Please note this is a MANUAL process and there are hundreds of volunteers working around the clock to generate the email that will connect you with a patron, so you may not hear from us for up to 5 days from the time you fill out this form. In some communities this time frame may be more and in some less - it really depends on the volume of patrons willing to assist in your area.

Some of you will have more than one patron assigned so you will get MORE than one email. We are trying to make you as whole as possible in the coming month(s) ahead.

This form will remain confidential and we will NOT share your personal information with anyone until you are matched up.

This is our time to come together as a community to support each other and to create an outbreak of LOVE over FEAR and we are so happy that you chose us to assist you in some way. It is an honor.

Sending you healing, love and freedom from suffering.

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Email *
First Name / Nombre *
Last Name / Apellido *
Age / Edad *
Best Phone Number to Reach You (With Area Code) / Número de teléfono para poder contactarte (Incluir código de área) *
Current City and State (If in the US, otherwise provide Country of Residence) / Ciudad y estado donde vives (si no vives en estados unidos, escribe el país en el que resides)
Current Zip Code if in the US (it helps us match you with someone more local potentially) / Código Postal si estas en USA (nos ayuda a conectarte con alguien más cercano o miembro de tu misma comunidad)
Current Occupation(s) / Ocupación (es)
Current Place(s) of Employment / Lugar(es) de empleo
Briefly describe the impact of the pandemic on your income (150 words or less) / Describe brevemente cómo la pandemia está impactando tu situación personal y/o tus ingresos (150 palabras o menos):
Please check off the assistance that would greatly help you at this time (check all that apply) / Selecciona el tipo de apoyo que solicitas. (selecciona todas las que apliquen): *
If you checked "Other" please explain further / Si marcaste la opción "Otro" en la pregunta anterior, por favor da una breve explicación.
Please indicate the approximate cost range of the assistance you are requesting. (e.g. "Gas for my car $50, Month of medicine for blood pressure $200, etc.) / Indica el costo aproximado de la asistencia requerida. (e.i. “$50 dlls para gasolina”, o “$200 dlls para un mes de mi medicina para mi presión alta”)
Is there anything else about your current situation or circumstance that you would like for me to know or convey to others? (e.g. single parent, kids rely on free lunch in school, etc.) / ¿Hay algún otro detalle de tu situación que creas importante o relevante comunicar para entender mejor tu situación?  (Por ejemplo, madre/padre soltero/a, pareja ingresada, etc.):
How did you hear about Pandemic of Love?
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