West Town COVID-19 Support Request Form
[UPDATE]: We have merged with Ukrainian Village Mutual Aid and are now using one central request form for everyone! Please go to this link to submit your request: https://docs.google.com/forms/d/1qUx31-eKvr-LTbpu2-T-wduzIPdoapfOnCig_Yf1yDM/viewform?edit_requested=true

If you live in the West Town neighborhood and would like food or other supplies dropped off at your front door, please use this form.

If you live outside of West Town, there are many neighborhood groups doing the same all across the city.

While we will do our best to address every request, we are a small, all-volunteer grassroots neighborhood network with limited funds.

Due to our limited funds and volunteers, we will prioritize people who are sick or have compromised immune systems, disabled, quarantined without income, economically disadvantaged, elderly, undocumented, queer, and/or people of color, or who have families in need.

Thank you and stay safe!
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[NEW LINK]
We have merged with Ukrainian Village Mutual Aid, and we now have one central request form here: https://docs.google.com/forms/d/1qUx31-eKvr-LTbpu2-T-wduzIPdoapfOnCig_Yf1yDM/viewform?edit_requested=true
Which one best describes your situation? *
Name (This does not need to be your legal name. Add your pronouns, too, if you want!) * *
Age
How should we contact you? * *
If you selected phone, what is your phone number? *
If you selected email, what is your email address? *
Delivery Address * *
How many people are in your household? *
Dietary Restrictions, Allergies, or Intolerances (Halal, kosher, vegetarian, vegan, allergic to peanuts, lactose intolerant, gluten-free, scent sensitive, etc -- this is important in case we're trying to substitute "our best guess for what you'd like" in place of "something you asked for" that's out of stock.) *
What types of food do you want? *
Grocery List (We cannot guarantee that we will get all of the items that you've listed. Items can be general like "milk," or specific like "a 24-pack of the purple Always brand overnight menstrual pads with wings." We will do our best to match your requests, but if we can't find something specific we may get you a similar substitute.)
Do you need someone to pick up your prescriptions for you? If yes, which pharmacy? (If yes, please provide us a phone number to reach you. We will need your legal name, date of birth, and the names of the medications. We will not collect this information on a Google Form (they are not secure enough!)
Do you have any other needs or requests?
What day do you need things by? Please allow us 48 hours to respond to your request *
MM
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DD
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YYYY
What time of the day do you need them by? (Please allow up to 48 hours for a request). *
Time
:
Any additional specifications, comments, questions, accessibility needs, or drop off instructions?
Submit
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