Request for Assistance due to COVID-19
If you have been DIRECTLY affected by the COVID-19 virus, and are in need of help in Clallam or Jefferson County, please complete this form and an OlyCAP staff member will contact you within 2 business days. Your need must be directly tied to the pandemic. If you are in need of general assistance, please visit our website.
First name *
Your answer
Last Name *
Your answer
Phone number xxx-xxx-xxxx *
Your answer
Email address _____@____.____
Your answer
Physical Address (Where are you sleeping most nights?)
Your answer
What city are you living in? *
Your answer
What do you need help with at this time? *
Required
Are you 60 years old or older? *
Are you a Veteran? *
Are you currently homeless? *
Do you have Coronavirus symptoms (cough, fever, breathing problems)? *
How is your need directly related to the pandemic? How have you been effected by COVID-19? (You may be asked to provide proof of loss of job/income; or positive test result.) *
Your answer
Are you currently working with an OlyCAP Employee or a Partner Agency (or is an OlyCAP/Partner Agency Employee completing this form)? Please list name of employee/contact information if you are a partner agency
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy