Horizons Church Coronavirus Outreach

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for your interest in helping the elderly and at risk population at Horizons.

We're in the process of assessing the current need and assembling volunteers. Our goal is to match one volunteer to one household in need.

If you're able to help shop for and deliver basic necessities like food, medicine, or household supplies for another family, please let us know by filling out the short form below.

Someone from Horizons will be in touch with more information.

First Name *

Last Name *

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Primary Phone *

Email *

I am comfortable helping: *

1 household in need

2-3 households in need

4-5

Required

Please indicate how you'd like to be reimbursed for your purchases: *

Venmo

Cash/Check

I prefer not to use my personal funds (please provide me with a source of payment)

I'd like to cover the costs for a household experiencing financial hardship

Required

Please confirm you are: *

Under 60

Free of a serious chronic medical condition such as asthma, heart disease or diabetes

Have NOT experienced upper respiratory symptoms, cough, or fever in the past 14 days

Other:

Required

Emergency Contact First and Last Name *

Emergency Contact Phone *

Please review "Horizons Community Church Volunteer's Waiver and Release" here: https://tinyurl.com/t4t4n7u *

I have read the "Horizons Community Church Volunteers’ Waiver and Release"

I agree to the terms in the "Horizons Community Church Volunteers' Waiver and Release."

Required

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms