Have a Need
We know that many people will have needs they cannot meet on their own during the "Shelter in Place" mandate. Please complete this form to communicate any essential needs you have during this time. Please be as detailed as possible to ensure we can connect you with the right person for aid.
Email address *
First Name *
Your answer
Last Name *
Your answer
What is your date of birth (mm/dd/yyyy) *
Your answer
What is your affiliation with Golden Hills? *
Address *
Please provide your house number, street name, city, state, and zip code i.e. 123 Elm St. Oakley, CA 94561
Your answer
Phone Number (xxx) xxx-xxxx *
Your answer
What type of need do you have? (check all that apply) *
Required
Please provide a brief description of the specifics of your need. *
Your answer
Where will this need be fulfilled? *
Please write alternate address in "Other..." field if different than above.
What days are you available? *
Required
What time of day you are available? *
Required
Submit
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