W.A.R.4Life, We Are Ready for Life Covid Relief for Alamance, Chatham, Guilford and Caswell Counties

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W.A.R.4LIFE, We Are Ready for Life has partnered with the North Carolina Department of Health and Human Services, and Southeastern Healthcare to link residents with the good folks in your community that are doing awesome, transformational work and have access to the much-needed resources during this pandemic. Please fill out this short form to be contacted about your needs. Resources include vaccination, food, transportation, prescription medicine delivery, COVID-19 supply boxes (face masks, gloves, sanitizer etc).

ALL INFORMATION IS HELD IN STRICT CONFIDENCE AND IS HIPAA COMPLIANT

Email *

By filling out this form, you agree to share information with a Network of health and social service partners powered by Unite Us software. Your personal information may be shared securely on the Network in accordance with privacy laws to connect you with services. This consent covers all information shared by you or by anyone that has the right to share information on your behalf. You can always limit the information you provide on the Network by requesting to have it removed. To understand how your information may be used and kept safe on the Network, please see https://uniteus.com/privacy If you no longer want your information shared on the Network, you can email consent@uniteus.com or ask any Network partner. It will take three business days to stop sharing your information. *

I agree

First Name *

Last Name *

Telephone Number *

What is your date of birth? *

YYYY

How old are you? *

What is your Race? *

What is your ethnicity? *

Hispanic or Latino

Not Hispanic or Latino

Are you a member of a State or Federally recognized Tribal Nation? *

Yes

What is your address? (PO Boxes not accepted) *

CITY in which you reside? *

COUNTY in which you reside? *

Do you have a disability? *

Are you currently employed? *

Yes

Household size (How many children and adults live with you )? *

Describe your current situation and other services you need. (If you request financial assistance, add how much money is owed/and to who for utilities, rent, bills etc.) *

Are you interested in the COVID Vaccine or booster? *

Yes

I'd like to learn more about the vaccine

What concerns (if any) do you have about receiving the vaccine? *

Are you in need of a COVID Test? *

Yes

Do you have any preexisting conditions that you feel may increase the risk of severe illness from COVID-19? *

Will you need transportation to/from your vaccination appointment? *

Yes

Maybe

Not applicable

Will you need transportation to/from your Covid Testing appointment? *

Yes

Maybe

Not applicable

Has anyone in your household, including you, been on Medicaid in the past 12 months? *

Yes

Would you like to enroll for Medicaid/Medicare? *

Yes

Maybe

Do you have a Primary Medical Provider? If so, who? *

Provide a secondary contact, in case we cannot reach you. *

A copy of your responses will be emailed to the address you provided.

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