"Nourishing the Community": A Partnership with The Center & Urban MO's - Jan 2021
The San Diego LGBT Community Center, in partnership with Urban MO's Bar & Grill, will be providing meals for community members who have been impacted by COVID-19. Please fill out the information below and you will be emailed a community meal certificate within 48 hours. The email will provide you with detailed information about the program and the certificate can be used to pick-up your meal at the restaurant. The certificate will only be valid between January 8-31, 2021. This survey form must be filled out for every community member (10+ years old) who is requesting a warm meal. For any additional questions, please email Sarah Merk-Benitez at
smerkbenitez@thecentersd.org
.
* Required
Email address
*
Your email
Name (Legal or Chosen)
Your answer
Pronouns
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Address
Your answer
Zip Code
*
Your answer
Phone Number
Your answer
If applicable, how many individuals in your household are 9 years old or younger and requesting a kids meal? (Please remember, all individuals 10+ years old requesting a meal must complete this form.)
Your answer
My race/ethnicity is (choose all that apply):
Asian
Black/African-American
Caucasian/White
Native American
Pacific Islander
Multi
Latino/a/x
Other:
My gender identity is (choose all that apply):
Woman
Man
Non-Binary
Other:
Do you consider yourself part of the LGBTQ community?
Yes
No
No, but I am an ally
Other:
Clear selection
Do you consider yourself part of the Transgender community?
Yes
No
No, but I am an ally
Other:
Clear selection
How have you (and your household) been impacted by the COVID-19 pandemic? (examples: Loss of job, Loss of hours, Older Adult/Senior, Immuno-compromised, caring for a family member, etc.)
*
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
Forms
