As a high-risk individual, I want to volunteer and offer assistance.
Ashton Heights Buddies seeks to help high risk individuals/families meet their basic needs during this trying time. For the purposes of this form, individuals who are considered high-risk include those who are 60 years of age or older, have compromised immune systems, and/or have been advised by a physician not to leave their home.
We recognize that individuals who fall into the high-risk category may also want to offer assistance while still maintaining social isolation recommendations set by the CDC. If an appropriate match is found or there is a need for virtual support, we will contact you. We will do our best to meet all requests but cannot guarantee a buddy match.
This match program is being organized by private citizens for the benefit of Ashton Heights community neighbors. By completing the sign-up form to be matched you agree that you accept all risk and responsibility and further hold any representative associated with Ashton Heights Buddies or the Ashton Heights Civic Association harmless. For any additional questions, please contact
AshtonHeightsBuddies@gmail.com
* Required
Name:
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Your answer
Email Address:
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Your answer
Phone Number:
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Your answer
Can you receive text messages at the above phone number?
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Yes
No
If no, provide an alternative number for texting:
Your answer
Zip Code:
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Your answer
Are you proficient in any language other than English?
Spanish
Other:
Do you live within the boundaries of Ashton Heights (between North Glebe Road and North Irving Street; and between Wilson Blvd. and Route 50)?
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Yes
No
If no, please specify your neighborhood:
Your answer
Are you interested in assisting Ashton Heights Buddies remotely?
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Yes
No
What can you offer assistance with?
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Your answer
Do you speak any language other than English?
Spanish
Other:
Do you agree to have your contact information (phone or email only, your address will not be given out) shared with the individual who will serve as your buddy for the assistance you are offering to provide?
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Yes
No
Waiver: By completing the sign up and clicking "I agree" below, I certify that I am at high-risk of developing serious complications from COVID-19, as determined by the CDC and that I am offering assistance while maintaining appropriate social isolation practices; I agree that I would like to be contacted by Ashton Heights Buddies to receive a buddy match; and I agree that I accept all risk and responsibility and further hold any representative associated with Ashton Heights Buddies and the Ashton Heights Civic Association harmless.
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I agree.
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