Family needs for COVID-19

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Heal Charlotte has developed a comprehensive survey during the COVID-19 crisis that will allow us to assess your needs. Although we cannot guarantee that every request will be fulfilled, a good faith effort will be made to address food needs, technology and connectivity needs, and stability and safety needs.

Heal Charlotte is partnering with Charlotte Mecklenburg Schools to identify the organizations in your area that can best meet your needs. Please take time to complete the entire survey.

*I give permission for my personal contact information to be shared with other organizations (non-profit, faith community, volunteer groups) in order to meet the various needs listed below. *

I give permission

Required

Name *

What is your email *

What is your address? *

What is your phone number? *

Please indicate what organization referred you to this form. *

Do you need any immediate supplies? *

Yes

If yes to the above question please list the supplies you may need below

How many dependent children live in the household? *

more than 5

Other:

What is your yearly household income? *

$5,000-$15,000

$16,000-$21,000

$22,000-$30,000

$31,000-$40,000

$41,000-$50,000

Other:

Have you recieved your stimilus check? *

Yes

Please list child/children's names and ages *

Would you like to have your children signed up for the Heal Charlotte Free Lunch Program or another free lunch program in your area? *

Yes

Required

Do you need meals delivered to you because you don’t have transportation or you have medical conditions that prevent you from traveling to pick up meals? *

Yes

Would you need assistance with childcare while you are at work (ages 6 and older)? *

Yes

What school does your child/children attend? *

Was your child/children provided a Chrome book from school? *

Yes

If yes, how many children recieved chromebooks from school. *

Do you need any assistance accessing Health screenings? *

Yes

Do you have any seniors 55+ in your house? *

Yes

If yes how many seniors do you have in your household? *

Are their any specific services they may need (transportation, pharmacy, health care?) *

Transportation

Medication

Health Care

None

Other:

Do you have access to technological devices at home, ex: computer, laptop, tablets, iPad, etc.?

Yes

Clear selection

Do you have internet access at home?

Yes

Clear selection

Have you received updates from Duke Energy and Spectrum about free WIFI and Duke Energy Bills?

Yes

Clear selection

If no to the above question, Spectrum will be providing free internet access to families that are not service connected for 60 days. Duke Energy will not be disconnecting energy services during this time. Would you like more information about how to connect with Spectrum or Duke Energy?

Yes

Clear selection

If there are any other needs that you may have please list them below.

Are you a resident of a Hotel/Motel for more than 30 days? *

Yes

What hotel do you currently reside in?

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