Senior Outreach during COVID-19
This form has been created so the Mount Airy Emergency Response Team and authorized users may reach out Mount Airy, MD senior citizens to provide information or for check-in calls. This list will NOT be shared with others.

DISCLAIMER: Callers do not have medical background and are not to give medical advice. These calls will be to chat with seniors, identify if there is a need to match a volunteer for a no-contact delivery or to provide information.

Maryland is providing a free service for daily health check-in calls. Please use this link to sign up for that service:
Please provide the name of the Senior Citizen.
Please provide the best phone number to reach this person.
Please provide the best email to reach this person.
Please provide the best address to reach this person.
Is there any other information we should be aware of?
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy