SAMPLE COVID-19 Volunteer Assistance Network Form

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To support efforts to mitigate the impacts of COVID-19, one thing we can do is support those close to us with compromised immune systems.

Those of us with strong immune systems can assist our neighbors. When we are well, we can buy groceries, pick up prescriptions, offer to walk our neighbor's dogs, provide social and prayer support via phone, or do other essential errands that will make it easier for our immune-compromised neighbors to self-quarantine.

I’m inviting residents of the [Neighborhood Name] to assist each other in this unprecedented time through a coordinated Community Volunteer Network to help our vulnerable neighbors shelter-in-place well.

Contact [Your Name] [Your Email] with any questions. Please complete the form below if you're able to assist.

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 interested to help in the following ways (check all that apply): *

Administrative Coordination for this Volunteer Response Network

Pickup/ deliver groceries for a neighbor in need

Pickup/ deliver prescriptions/medications for a neighbor in need

Provide social/ emotional support via phone

Provide Prayer Support via phone

Walk a dog

Other:

Required

Is there anything else you'd like us to know?

Submit

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