Seeley Swan Helps Assistance Application

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If you are at high risk for the CoronaVirus (either due to your age or because you have a serious long-term health concern.) AND you are staying at home as much as possible, please answer the following questions.

After you fill out this application, we will contact you to confirm that we have received your application.

Email *

1. Are you choosing to isolate yourself in your home due to concerns about the CoronaVirus/

Yes

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2. Do you have a family member or friend who are assisting you with groceries, supplies, prescriptions, posting mail, or other necessary tasks while you are isolated due to Corona Virus?

Yes, I have someone helping me as they are able. (What areas do you need help?)

No, I do not have anyone helping.

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3. While you are waiting for the Corona Virus to pass, will you need help with the following? (Please check the boxes below that apply)

Picking up groceries or other supplies

Picking up prescriptions

Picking up non-script Medical supplies? (Incontinence, diabetic, over-the-counter medicines)

Posting or picking up mail

Is there an area of service that you need that is not listed above?

Name

Date

YYYY

Phone Number

Address (Include Town)

Is this urgent? (an urgent situation is: No food, Medications are out or will be out before the next pharmacy time)

Yes

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Emergency

If this is an emergency: Please call 911

Hours of Operation for Phone & Email

9 a.m. - 6 p.m.

Contact Information

Seeley Swan Helps 406-239-9617 seeleyswanhelps@gmail.com

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