UU Church of Bloomington  -------------- Caring for Our Community
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As the Covid-19 pandemic unfolds, it is important for our church community to be able to care for and support each other.  In order to facilitate this, we are asking you to complete this questionnaire as soon as possible. The information you provide on this form will be kept confidential. If you have questions about this questionnaire, please email Ann LeDuc at connect@uubloomington.org .
Your Name *
Physical street address (not PO box)
Your Age
Phone number
Email address
Names of other people living in your household and their ages
Emergency contact who does not live with you:  Please include name(s), relationship, and contact Information
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