Jefferson & Gladstone Park Mutual Aid Request Form
If you would like food or other supplies dropped off at your front door, please use this form. You can request this whether or not you need financial assistance to purchase these things!

**Donate via GoFundMe** https://www.gofundme.com/f/jefferson-park-mutual-aid?utm_source=customer&utm_medium=copy_link-tip&utm_campaign=p_cp+share-sheet

**View this form in another language**

Español (Spanish): currently unavailable, but in the works

** Questions, updates or want to get involved? **
Sign up to volunteer -- https://forms.gle/fx83CVrMHPNgJMCV7
Contact us -- jeffmutualaid@gmail.com
Our Facebook group -- https://www.facebook.com/groups/jeffmutualaid/

We are an all-volunteer group who has assembled to care for our local community during this time. Together, we can individually assure that our community members remain resourced and cared for. We will try to let you know if we can meet your request within 48 hours. We're so glad you've reached out to us for support and want you to know that you are cared about.

(A big thanks to Rogers Park and Pilsen mutual aid funds for the format adapted in this form)
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Your name (this does not need to be your legal name!) and pronouns (ex: she/her, they/them) if you would like to share with us! *
How should we contact you? (choose at least one) *
Required
What is your email? (leave blank if you do not have or do not want to use your email)
What is your phone number? (leave blank if you do not have or do not want to use your number)
How many people are in your household?
Dietary restrictions?
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 would you like? *
Required
Your grocery list *
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. We trust you to know your needs and we are committed to delivery without judgement.
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 needs or requests that haven't been covered yet?
Would you like financial support? *
Drop off address and any drop off instructions? *
What day do you need this by? *
We will do our absolute best to accommodate your needs within 48 hours, but we can't guarantee timing.
MM
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What time do you need this by? *
We will do our absolute best to accommodate your needs within 48 hours, but we can't guarantee timing.
Time
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