Community Needs & Resources Survey
Name *
Phone
In case you request or offer aid, we'd like to be able to reach you.
Email *
Address
This helps us identify mutual aid opportunities and resources near you.
Facebook
Provide the LINK to your Facebook page (e.g., facebook.com/YOURNAME)
City
Rate your experience so far with the Coronavirus Mutual Aid Network of Brevard.
Awful
Awesome
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Are you elderly, immunocompromised, or otherwise unable to leave your home?
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MUTUAL AID BRIGADE: Are you willing and able to deliver groceries, food or medical supplies to the elderly, immunocompromised or those unable to leave their homes?
By selecting “Yes” below, you are indicating that you personally accept any related risk related with delivering supplies, that you are healthy and not in a high-risk category, that you are personally practicing isolation except for necessities, that you will not participate if you or your family are experiencing any symptoms of coronavirus, and that you that you will use safe practices, including social distancing, to transport and deliver any necessary items.
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May we publicly share your name, phone number & email for potential delivery requests?
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What other skills and resources do you have to share with our community?
May we publicly share your name, phone number & email with those who may need your skills and resources?
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SUPPLIES: Do you have supplies that you are unlikely to need? If so, what supplies are you able to share?
May we publicly share your name, phone number & email with those who may need your excess supplies?
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If people in our community request funds for groceries, medication, diapers, or similar necessities during the crisis, are you willing to donate small amounts for emergency aid directly to the recipient via a cash app like Venmo or PayPal?
GOFUNDME: Are you interested in supporting a community GoFundMe account to meet urgent needs for local people?
We are considering establishing a GoFundMe account to meet the immediate basic needs of local people during this crisis. Please check the amount you would be likely to contribute this month if we established a GoFundMe page to fund small cash grants to local people in need. (Note: This is only in the idea phase, and your response is not a commitment.)
Do you prefer to make direct personal donations to recipients via Venmo or PayPal, or to a community GoFundMe account?
Are you connected to a community charity or foundation who might be willing to administer donations to help make immediate cash grants to neighbors in need
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Do you have any needs for assistance?
We want to understand the needs of our community so we can do our best to identify aid resources, but unfortunately cannot commit to meeting all the needs our community may face.
Immediate Need
Next 30 Days
Long Term
Shopping & Delivery of Food or Medication
Childcare
Employment
Education/Tutoring
Financial Assistance - Food
Financial Assistance - Healthcare
Financial Assistance - Utilities
Financial Assistance - Rent/Mortgage
Financial Assistance - Other
Meal Preparation
Mental Health Services
Shelter
Social Services (Unemployment, SNAP, etc.)
Transportation
Other
Have you posted any requests for aid or assistance on the Coronavirus Mutual Aid Network of Brevard County Facebook page? If so, did you receive the aid you needed?
Have you received any useful information, resources, or inspiration from the Coronavirus Mutual Aid Network of Brevard County Facebook page?
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Do you own or work at a local business that is currently open to the public? If yes, please share current hours and details. If your local business is has any charitable offers for those in need, please share those as well.
May we publicly share the information provided about your local business?
Clear selection
What types of aid do you believe will be most important for our community over the next 30 days?
Is there any feedback you’d like to share about the Coronavirus Mutual Aid Network of Brevard or any suggestions you’d offer for improvements?
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