Get Help: Request Form

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The purpose of this form is to identify needs for the most vulnerable in our community and to match them with someone who can help. Once a match is made, please coordinate with the volunteer for the delivery of essential supplies, like food, toiletries, and prescriptions. Feel free to check in on one another too. However, please follow CDC guidance to mitigate community spread.

This match program is being coordinated by volunteers for the benefit of those in our community. We will do our best to meet all requests but cannot guarantee a match and/or financial assistance. We are handling the most urgent requests first. We're learning how to look out for each other as things are evolving every day. Please grant us some grace.

Name *

Phone *

Email Address *

Which of these ways are best to get in touch with you? *

Text Options

Phone Call

Do you prefer to communicate in a language other than English?

If so, please specify the language below. You can skip this question if you're 100% comfortable being contacted for support by an English-speaking volunteer.

Spanish

Other:

Clear selection

How soon do you need support? *

Please bear in mind that we are not an emergency service entity. We'll be as quick as we can responding to support requests made through this form. However, if you're in immediate crisis and need intervention right now, please call 911.

As soon as possible

In the next few days

I'm okay for now, but am worried that I won't be soon

Cross Streets

Neighborhood

Zip Code

What type(s) of support are you seeking? *

Help running errands out of the house (picking up groceries, prescriptions, walking dog, etc.)

Someone to check-in on me and provide some social connection (phone check-ins, text messages, etc.)

Help identifying resources to meet my basic needs (SNAP, low-cost food resources, unemployment insurance, etc.)

Other:

Please feel free to provide more information on what you need assistance with.

If you are completing this form for someone else, please note that here, as well as their contact information.

Do you require financial assistance? *

Note: This mutual aid group is a small community response matching neighbors to neighbors. There are a limited number of neighbors who can help with financial needs. We do not provide direct aid and cannot guarantee your financial needs will be met.

Yes

Anything else you want to share about your situation at this time?

Please note this is not a secure form, so we strongly urge you to not share private or medical information you would not share on Facebook.

Do you agree to have your contact information (phone or email only, your address will not be given out) shared with one individual who will serve as your buddy? *

Yes

Waiver of Participation and Responsibility *

By selecting "I agree" below, I agree that I would like to be contacted by this mutual aid group to receive a match and/or be contacted by my match directly. By completing the sign up form to be matched to receive or provide voluntary services, you agree that you accept all risk and responsibility including any injury or harms that may result from providing or receiving services, and further hold any facilitator associated with this mutual aid group harmless. We are not healthcare professionals, if you need medical advice, please call your physician or 911.

I agree.

Required

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