SAMPLE COVID-19 Assistance Request Form

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[Neighborhood Name] is coordinating a Volunteer Neighborhood Assistance Network to help you shelter in place if you're exhibiting COVID-19 symptoms or have a compromised immune system and have been advised to stay home.

Please fill out the form below to be paired with a neighbor close by if you need assistance with:
- Grocery pickup and delivery
- Prescription pickup and delivery
- Dog walking
- Social/ emotional support by phone
- Prayer support by phone
- Other essential errands outside the home

If you know of an older adult or immune-compromised neighbor that doesn't have access to the internet, please share this information with them.

Email *

First Name *

Last Name *

Phone Number *

Preferred method of communication *

Phone

Text

Street Address (so we can match you with someone close to you) *

I'm requesting help in the following ways (check all that apply): *

Grocery pickup and delivery

Prescription pickup and delivery

Dog Walking

Social/ emotional support by phone

Prayer support by phone

Other:

Required

Anything else you'd like us to know?

Submit

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