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**THIS FORM IS NO LONGER IN USE. If you landed on this page, please email stlquarantine@gmail.com.** STL Quarantine Support - Intake Form
**THIS FORM IS NO LONGER IN USE. If you landed on this page, please email stlquarantine@gmail.com.**
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Providing this information will allow us to quickly get in touch with you and reference basic information to complete deliveries. The information provided here is only accessible by a core group of trusted volunteers. Requests for specific supplies will be made using a second form that is available here:
https://tinyurl.com/STLQSrequest
Would you like to receive deliveries of groceries and other necessities from volunteers?
*
Yes
No
Do you have enough money to purchase the supplies you need? *Financial assistance is based on individual donations. Because of the uncertain nature of these donations, we are unable to guarantee that we will be able to help you financially with your groceries.*
*
Yes
No
Do any of the following apply to you?
*
Currently have fever, cough, shortness of breath, or other respiratory symptoms
Immunocompromised
Over 65 years old
Have a disability
Caregiver to one of the above
Self-quarantining due to high-risk travel
None of the above
Required
Do you require additional support (other than deliveries) to maintain quarantine?
Yes
No
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First Name
*
Your answer
Last Name
*
Your answer
Pronouns
they/them
she/her
he/him
Other:
Email
*
Your answer
Phone
*
Your answer
Street Address
*
Your answer
City
*
Your answer
ZIP Code
*
Your answer
Best Method of Contact
*
Email
Call
Text
Social media (add info in "other")
Other:
Required
Emergency Contact Name
Your answer
Emergency Contact Phone
Your answer
STL Quarantine Support is a volunteer run effort. Volunteers are not medical professionals. Participants should assume that all deliveries have not been sanitized. Individual participants should take steps to protect themselves once the items are delivered.
*
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Required
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