Lakeview/Lincoln Park Mutual Aid COVID-19 Support Form
If you need support with food, prescription pick-ups, caregiving, medical supplies, and more, please use this form to let us know how we can assist.

We are an all-volunteer grassroots group operating in the Lakeview/Lincoln Park neighborhoods.

NOTE - This form is not for financial needs. We don't currently have the ability to meet direct cash assistance needs, but we may be able to offer it in the future.
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Name (This does not need to be your legal name. Add your pronouns, too, if you want!) *
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How should we contact you? *
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Required
If you selected phone, what is your phone number?
If you selected email, what is your email address?
How many people are in your household?
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Have you been diagnosed with or do you have symptoms of COVID-19 such as a low fever, coughing, cold symptoms, or fatigue? *
How can we assist you?
Additional notes about assistance needed.
Do you need someone to pick up your prescriptions for you? If yes, which pharmacy?
If yes, please provide us a phone number to reach you. We will need your legal name, date of birth, and the names of the medications. We will not collect this information on a Google Form (they are not secure enough!)
Where in the neighborhood are you located?
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Will we need your address to assist? *
Choose yes if you need groceries, medication, or something else picked up or dropped off.
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