JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
QA Coronavirus (COVID-19) Assistance
Sign in to Google
to save your progress.
Learn more
* Indicates required question
"Officially" which community are you in
*
Queen Alexandra
Allendale
Other:
Which of the following brings you here? (You can choose multiple)
*
I would like to receive some assistance with tasks
I would like to volunteer
I would like to be kept updated by email on community COVID initiatives and strategies
Other:
Required
Privacy: Please indicate that it is okay that your answers are shared with the 5 core members of the QA COVID committee. The information will be kept secure and confidential between these members.
*
Yes
Name (First, Last)
*
Your answer
Your Address (Street Address, Postal Code)
*
Your answer
Your Phone Number
*
Your answer
Your Email Address (If Available)
Your answer
General Age Group
Choose
17-24
25-35
36-45
46-55
56-65
66-75
76-85
86+
If you indicated that YOU WOULD LIKE SOME ASSISTANCE with tasks, which areas do you want support with? [NOTE, if you are here to volunteer or get on the email update list, choose first option)
*
None - I am filling this form to volunteer or get on the email update list
Grocery Shopping
Prescription Pick UPs
Transportation
Online Access and Form Filling
Mail/Parcel Delivery/ Pick Ups
Pet Walking
Social Activities (covid-safe, like online activities)
You, your kids, or someone you know, needs help with internet access, needs computers/tablets to be schooling online, or to be socializing online
Other:
Required
Please select one of the following that best describes your current situation. This information is only to make sure we make the best matches between people and approach.
*
COVID-19 positive (quarantine)
At-risk (e.g. Senior, compromised immune system, pre-existing condition, etc)
Self-Isolating for other reasons (e.g. Recent Travel, single Parent, person with a disability, others)
I do not fit in any of these categories
Other:
Required
Anything else we should know? If you have information that might help us better understand your situation, type it below. If you have special needs, indicate what they are below.
Your answer
Would you be interested in strategies to reduce exposure to individuals, such as "pooled-shopping" for residents of all risk groups? *Pooled-shopping means one resident trained in decontamination measures shops and delivers to a few residents, to reduce numbers of individuals in public spaces.
No, thanks
Maybe
Yes, likely
Clear selection
If you indicated that you WOULD LIKE TO VOLUNTEER , which areas can you help support? [NOTE, if you are here to receive assistance or get on the email update list, choose first option]
None - I am filling this form to request assistance or get on the email update list
Grocery Shopping
Prescription Pick UPs
Transportation
Online Access and Form Filling
Mail/Parcel Delivery/ Pick Ups
Pet Walking
Social Activities (covid-safe, like online activities)
Delivering fliers to mailboxes
Other:
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
This form was created inside of Queen Alexandra Community League.
Report Abuse
Forms
