Wellness Check Request Form - COVID-19
On Monday, March 16 the Hardee Help Center activated emergency relief efforts with the focus of our efforts on the most vulnerable in Hardee County. We are doing our part to help ensure the health, safety, and food security of our community.
With the help of concerned citizens we can identify people who might benefit from these wellness check calls. Staff and/or volunteers will place calls each week to identify any immediate needs. NOTE: Please know our callers will mention you by name as the person who was concerned about their well being.
What is your first, last name?
What is the name of the person you would like the Hardee Help Center to check on? (First, Last Name)
What is the person's phone number? (Ex. xxx-xxx-xxxx) This will be the best way for HHC Staff to contact the person. If you do not have the phone number, provide their address.
What is the person's address? (Ex. 713 E. Bay Street, Wauchula) Provide if you know it. This will be helpful if we are unable to reach the person by phone.
Do you know the person's age?
Atleast 65 or older.
Younger than 65 years.
Is this person related to you?
Do you know if this person is a member of a local church?
Yes this person is a member of a local church.
Yes, but I don't know which church.
Yes, but the church is unable to help.
No, I don't know if this person is member of a local church.
Do you have any additional comments?
Never submit passwords through Google Forms.
This form was created inside of Hardee Help Center.