COVID-19 Mutual Aid Grocery Delivery

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

We can't guarantee we can take all orders. At this time, we can only handle 10 orders on each delivery day, although we may be able to take more orders per week in the future. We will send you confirmation if we are able to process your request.

Email *

Phone Number: *

Name *

Best way to contact you: *

Phone

Street Address (and nearest cross street) *

City *

Zipcode *

Would you like to learn more about community organizing in Champaign-Urbana with the Party for Socialism and Liberation? *

Which of the following dates is preferable for delivery of your groceries? We will contact you about specific times for delivery. *

Friday

Saturday

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms