40th Ward COVID-19 Community Response Request Form

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Do you need help?

Neighbors in the 40th ward understand fundamentally that we are one community, willing to support one another in these trying times.

As we each become accustomed to our new normal, we are collecting contact information of neighbors in the community who may need extra support during this time.

If you would like to have a 40th Ward Community Response Volunteer do daily check-ins with you via phone or email, please complete this form to your best ability. Thank you for being a part of our community!

Email address *

First Name *

Last Name *

Phone number *

Home address (we will try to assign volunteers to check in on folks who live near to them) *

Do you have any health concerns we should be aware of?

What services and support would be most helpful?

Regular Wellness Checks

Regular Covid 19 information updates

Pick up/Drop off Assistance (groceries/prescriptions/supplies)

Other:

Do you have a preferred language?

Submit

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