COVID-19 Elderly Emergency Supplies

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For our Seniors ages 70+

Email *

Are you between the ages of 65-110 years of age? *

Yes

Applying on behalf of someone between the ages of 65-110?

Other:

Are you currently employed?

yes

Clear selection

Phone Number

Include first and last name of applicant. This is a need based program, please elaborate and describe need:

Do you/or the applicant have family members who are caring for you during COVID-19

yes

Clear selection

How did you hear about this program?

Chapter House Staff

UNHS Employee

SJSD Employee

Clear selection

Physical Directions to Home:

Navajo Language Prevention and Precautions

Are you exhibiting symptoms of cough, fever, and trouble breathing. We urge all patients to stay home and self-isolate if you only have MILD or Moderate symptoms and call your doctor if you are experiencing SEVERE symptoms. Do you or anyone at your residence exhibit any of these symptoms?

yes

Clear selection

Are you currently experiencing shortness of breath or trouble breathing?

yes

Clear selection

Send me a copy of my responses.

Submit

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