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Epiphany Cares
Make Request for Service
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Name (First & Last)
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Your answer
Telephone Number
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Your answer
Email (optional)
Your answer
Street Address (including apartment #, if applicable)
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Your answer
City
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Your answer
Zip Code
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Your answer
What would you like? Please be as specific as possible, including quantities, etc.
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Your answer
What store(s) would you like the volunteer to buy these items from? ("Don't Care" is a perfectly acceptable answer!)
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Your answer
How would you like to pay for your order? (Note: We're free, this is how you'd like to pay for the order itself :) )
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Order ahead to the store (best option if possible!)
Give money to the volunteer before they get the order
Have volunteer pay for the order and reimburse when they deliver
Anything else you would like to tell us?
Your answer
Safety Protocol
PLEASE NOTE: If you are experiencing symptoms of COVID-19, we ask that you not reimburse your volunteer in cash but through Venmo or another payment app. Or call ahead to the store. Please do not open the door until the volunteer has left the premises.
We want to help you get what you need while staying safe. Please fill out this form so that we can bring things to you!
I have read Epiphany Cares' safety protocols and agree that Epiphany Cares is not liable for theft, fraud, contagion, or disclosure of any private medical information or other confidential information.
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