I AM OVER 60 AND/OR HIGH-RISK AND IN NEED

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If you are over the age of 60 and/or high-risk for COVID-19 and in need of assistance, please complete this form. Once you have filled out this form, a volunteer will contact you to coordinate the delivery of essential supplies, like food and prescriptions.

Please call Norton Christian Church at (785) 877-2871 with additional questions.

Name *

Phone Number *

Address (Street, City, State, Zip) *

Please select which one applies... *

I am over 60 or have a pre-existing condition and would like to sign myself up for COVID-19 assistance.

I would like to sign up my loved one for COVID-19 assistance.

Required

Please select your needs... *

Grocery Shopping & Delivery

Pharmaceutical Pickup & Delivery

Financial Assistance (only used toward essential supplies)

Other:

Required

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