I am requesting assistance.

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Ashton Heights Buddies seeks to help high risk individuals/families meet their basic needs during this trying time. 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. For the purposes of this form, individuals can be high-risk or simply in need of assistance.

Individuals at highest risk of developing serious complications from COVID-19 will be prioritized. These include those who are 60 years of age or older, have compromised immune systems, have been advised by a physician not to leave their home, and/or are economic hardship.

Once a match is made, you and your buddy can coordinate your interaction. This could consist of the delivery of essential supplies, such as food, toiletries, and prescriptions. You and your buddy can also help one another feel less isolated by checking-in on the phone, texting or other electronic means. Please follow all directions provided by the CDC to mitigate spread of the virus.

We will match you with someone in Ashton Heights as soon as a volunteer becomes available. 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 those in our Ashton Heights community. 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

Name: *

Email Address: *

Phone Number: *

Can you receive text messages at the above phone number? *

Yes

If no, please provide an alternative number for texting:

Preferred method of communication: *

Phone Call

Text Message

Do you live within the boundaries of Ashton Heights (between North Glebe Road and North Irving Street; and between Wilson Blvd. and Route 50)? *

Yes

If no, please specify your neighborhood:

Closest cross streets to your residence? *

Please do not provide your exact address.

Zip Code: *

What do you need assistance with? *

Select as many as apply.

Help running errands outside the house (picking up groceries, toiletries, prescriptions, etc.)

Someone to check-in on me and provide some social connection (phone check-ins, text messages, walk-bys, etc.)

Other (if this box checked, please provide additional detail in the following field)

Required

Please feel free to provide more information on what you need assistance with.

If you are completing this form for someone else, please note that here, as well as their contact information.

Do you require a buddy who is proficient in a 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 requesting? *

Yes

Waiver: By clicking "I agree" below, I agree that I would like to be contacted by Ashton Heights Buddies to receive a buddy match. I also 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. * *

I agree.

Required

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