Lake County Request for Support

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Lake County is full of wonderful people willing to help those in need. Please use this form to request assistance due to hardships your household is experiencing due to the impact of COVID-19. Examples of assistance that may be available include but are not limited to emergency food assistance, masks, and snow removal. Please be sure to enter a working phone number so we can follow up and help connect you to the appropriate supports.

If you need financial support please use this form https://docs.google.com/forms/d/1SLzxN4WeCNhdhyNKuV74N2vi8EJHi7S7e4sAGg2raD0/viewform?gxids=7628&edit_requested=true

This form is checked Monday-Friday at 8 AM.

Please provide your name.

Please provide your phone number. *

Please provide your address.

Are you or anyone in your household currently experience any of the below symptoms, or have you been in close proximity to anyone who has been ill in the last 14 days? Symptoms: Runny nose, Sore throat, Cough, or Fever. *

Are you in self-isolation or doctor-ordered isolation/ quarantine? *

Is your need for support urgent or could you wait a few days for others to be served first?

Urgent

I can wait

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When would be the best day and time to receive support? *

Which of the following support options are you in need of? Check all that apply *

Food Pantry Information or delivery of food for those in quarantine or without transportation

A phone buddy to communicate with

I need a reusable mask

Snow Removal

Required

Thank you for taking the time to complete this form.

Someone will be in contact with you as soon as possible.

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