COLORADO PANDEMIC RELIEF (CPR) Support Request

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We emphasize solidarity & mutual aid for all people, always.

ALL REQUESTS ACCEPTED

A True Change collects information to identify your specific needs and data to demonstrate our impact. Your privacy is our priority; we won't share your personal information. All questions are optional, yet we encourage your detailed response.

Thank you for allowing us to serve you and understand your needs.

Executive Director

Tara Barnes

Email *

Name *

Address *

Phone

Do you need delivery or can you pick up your supplies? *

I need delivery

I can pick up my supplies

I can pick up my supplies and deliver 1-5 packages on the same day to my neighbors

I can pick up my supplies and deliver 5+ packages on the same day to my neighbors

Our staff must be able to contact you to make arrangements, please list your preferred method of contact. *

Household Size (yourself, and your dependents) *

How many children are in the household?

Other:

Clear selection

What ages are the children in your household (check all that apply)

1-3

4-6

6-10

11-13

14-18

Is your household receiving free or reduced lunch at school?

Yes

Not sure

Clear selection

Is anyone in your household high-risk, mobility-impaired, or considered disabled? *

Yes

If yes; please list the diagnosis

How many seniors are in your household?

Clear selection

Please indicate your top 3 needs (additional needs can be specified in the next question). The two food categories help to identify your specific needs. Please answer truthfully and select the options that are best for your family; were working diligently to fulfill your needs to the best of our ability *

Food (all)

Food (fresh)

Household Cleaning Products (includes toilet paper, sanitizers, wipes, vinegar/bleach, etc)

Baby Products (diapers, formula, wipes, etc)

Personal Hygiene Products (shampoo, toothpaste, feminine hygiene products, etc)

I'm high-risk or have mobility issues and need errand assistance

Other:

Required

Please write some of your most-needed items. We will do our best to fill these needs first.

Does your household identify as... (Optional)

Very Low Income

Low Income

Working Class

Other:

Clear selection

Ethnicity. Please check all that apply to your household. (Optional)

Black/ African American

Hispanic/ Latino(a)

Asian

Native American

Middle Eastern

Mixed Race

White/Caucasian

Other:

Does anyone in your household identify as any of the following? Select all that apply. (OPTIONAL QUESTION Used for statistical purposes only, and to identify additional support per your request.)

LGBT+

Disabled

Immigrant

Refugee

Undocumented

Survivor of Domestic or Sexual Violence

Involved with Gangs

Incarcerated (formerly or currently missing a household member due to incarceration)

Homeless or Unstable Housing (shelters, staying with friends, lack of water/electricity or risk of losing water/electricity/house)

Limited English Proficiency

Other:

How has COVID affected your household? Select all that apply. (Optional)

Bartender/food service worker that has lost job or reduced hours

Lost job or reduced hours

Small business owner/employee that has reduced income

Dealing with educating children at home

Extra costs for cleaning/safety supplies

Musician/artist/freelancer/gig worker that has lost income

Other:

Would you like to receive updates from A True Change (ATC)? *

I would like updates from A True Change

I DO NOT want updates from A True Change

Would you like additional support from ATC? Please choose all areas of needed support to initiate the refurl process.

Housing support (rent/utilities assistance, etc)

Ongoing food or essentials support

Youth engagement, education, and empowerment

Gang involvement (all ages)

Adult education and empowerment

Assistance applying for low-cost internet and computers/laptops

Education or entertainment resources for kids staying home from school

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