I AM UNDER 60 AND LOW-RISK AND WILLING TO VOLUNTEER

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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 you will be contacted on an as-needed basis and be responsible for coordinating 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 *

Email *

Phone number *

Street Address & Zip Code *

I agree to... *

I am under 60, low-risk and healthy and want to help those in need.

Required

I am willing to help by... *

Grocery Shopping & Delivery

Pharmaceutical Pick Up & Delivery

Financial Donation (used only toward essential supplies)

Other:

Required

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