Pantego Citizen's COVID19 Assistance Request

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

During this time of COVID-19, the impact on our daily lives is substantial. Simple tasks such as shopping or getting gasoline now require intentional thought for personal protection. Many of us have been affected in other tougher ways, but all of us have to do our part to continue to prevent the spread of this terrible virus. We recognize as a smaller community we have the unique opportunity to help each other stay healthy by staying home as much as possible, especially those at highest risk. The CRB Task Force is organized to help connect needs of our community to those that can help.
Several examples of needs that we can help with include: shopping assistance, meal delivery, prescription pickup

****all information gathered as part of this process will be kept confidential and shared only with essential members of this team****

Name of Person Filling Out This Form *

Phone Number Person Filling Out This Form *

Name of Person/Family Needing Assistance *

Primary Phone Number *

Secondary Phone Number

Email address *

Address *

Is any member of this household considered high risk for COIVD19? *

Yes. One or more of the following: respiratory history, elderly, immunocompromised

unknown

Please tell us about your needs and how we can help you. *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms