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Westchester (COVID-19) Help Request
IF YOU HAVE AN EMERGENCY PLEASE CALL 911, This is a non emergency support group
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* Indicates required question
Your Name
*
Your answer
Your Address
*
Your answer
Your Telephone
*
Your answer
*
Mobile Phone
Land Line
Required
email address (if have one)
Your answer
What kind of help you need
*
Your answer
Special Instructions
Your answer
If you need our help to do shopping, What will be your payment method?
Cash
Check
Credit Card
Paypal
Venmo
Zelle
Other
How soon you need it
*
No urgent
Urgent
Please write your Name and phone if you are filling this form on behalf of someone else.
*
I'm filling this form for myself
Other:
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