Benton Park COVID-19 Delivery Assistance Form

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In the last week, many neighbors have reached out offering to deliver groceries, prescriptions, etc. to neighbors who are immunocompromised, elderly, or otherwise unable to obtain necessary supplies.

If you or someone you know needs help with a delivery to the Benton Park area, please fill out the form below. A member of the BPNA board will be in touch. Questions? Email covidrelief@bentonpark.org.

Your Name (First and Last) *

Your Email *

Your phone number *

Who needs delivery support? *

Myself

A neighbor or someone I know

Other:

Do any of the following apply to you (or the person who needs delivery)? *

Currently have fever, cough, shortness of breath, or other respiratory symptoms

Immunocompromised

Over 65 years old

None of the above

Required

Address for Delivery *

What type of support do you (or the referred individual) need? *

Grocery Delivery

Prescription Delivery

Other:

Required

Please provide some information about the support you need and how COVID-19 has affected you (or the referred individual). *

Submit

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