I AM OVER 60 AND/OR HIGH-RISK AND IN NEED

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We are preparing for and limiting exposure of COVID-19 in the Belleville and Republic County community by identifying healthy adults who are under 60, whose risk factors are low and who are willing to volunteer for an elder or someone with high risk factors in our community. Once you have filled out this form a volunteer will contact you to coordinate the delivery of essential supplies, like food and prescriptions.

Please call Belleville Chamber & Main Street at 785-527-5524 or email mainstreet@nckcn.com with additional questions.

Name *

Phone number *

Street Address & Zip Code *

I agree to... *

I am over 60 or have a pre-existing condition and would like to sign myself up for COVID-19 assistance.

I would like to sign up my loved one for COVID-19 assistance.

Required

Please select your needs *

Grocery Shopping & Delivery

Pharmaceutical Pick Up & Delivery

Financial Assistance (only used toward essential supplies)

Other:

Required

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