Bronx Mutual Aid Network for COVID-19 "Volunteer" Form

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

Hello!

The Bronx Mutual Aid Network for Covid19 is an entirely volunteer-run, community-funded initiative which relies on donations (https://chuffed.org/project/bxmutualaid) to help those that are most needy/vulnerable at this time and cannot receive help from the city or state government. These are folks such as: undocumented families, elderly folks, those who are ill and/or disabled and cannot leave their homes. Please be mindful when sending requests.

Mutual aid is about community members providing direct support to our neighbors in times of need, and generally fostering greater human connection. Mutual aid volunteers may be able to provide medical supplies, groceries, small-scale financial support, child or pet care, companionship, and other forms of assistance. Neighbors throughout Bronx and NYC, are providing mutual aid to those facing hardship due to the impacts of the novel coronavirus (COVID-19) pandemic.

We are an all-volunteer grassroots group operating in the various neighborhoods of The Bronx. We want to help folks who are sick, disabled, quarantined without pay, elderly, undocumented, immigrant, queer, Black, Latinx, Indigenous, etc.

Please fill out this form if you would like to help us coordinate food and supply drop-offs to people's front doors. Please use this form if you would like to help make deliveries. Thank you!

If you can't deliver things but would like to make phone calls, help people fill out forms for government assistance, financial grants, fill out this form.

If you can provide legal support, fill out this form! Thank you.

If you're looking for help please email BXmutualaid@gmail.com or fill out this form with your info.

This list will only be shared with others doing mutual aid work and folks who need mutual aid. We won't use or share your info for any other purpose.

Stay strong and be safe! We are doing our best to respond to new developments as quickly as we can. Please bear with us.

PLEASE JOIN OUR FACEBOOK GROUP "Bronx Mutual Aid Network for Covid19": https://www.facebook.com/groups/161738325111768/?ref=share

THANK YOU.

Email *

What are your pronouns?

He/him

She/her

They/them

Other:

Clear selection

What is your full name? (This does not need to be your legal name.) *

Cell Phone Number *

Do you have access to a vehicle?

Yes

Other:

Clear selection

Which neighborhood are you based in? *

What languages do you speak? *

Are you able to help us translate writing? Could you interpret a conversation in person or by phone?

What neighborhoods would you prefer to deliver to? (please write out names of neighborhoods)

How do we get in touch with you? (Please give several options if possible.) *

Phone call

Text message

Other:

Required

Would you like to help pay for groceries/supplies? (We want to ensure that those who want to provide mutual aid do not face undue burden and we absolutely do not expect you to spend money if you are financially limited.)

No. I will need money ahead of time in order to buy the groceries.

No. I have the money to make the initial purchase, but I will need reimbursement.

Yes. I will donate any groceries I pick up.

Depending on the items I might be able to donate any groceries I pick up.

Other:

Clear selection

Do you need money for transportation? (We want to ensure that those who want to provide mutual aid do not face undue burden.)

Yes. I would like to be reimbursed for gas/bus or train fare.

Clear selection

What type(s) of money transfer work for you?

Cash

Check

Venmo

PayPal

Other:

Are you comfortable picking up prescriptions? (We will help coordinate any paperwork needed and pharmacy location.)

Yes

Other:

Clear selection

Are you 21+ with a valid ID?

Yes

Other:

Clear selection

What's your address? (Doesn't need to be your actual home address, could just be an address nearby. This is only for the purpose of matching you with someone closest to your neighborhood. Please include zip code.)

Are you able to make a financial donation to someone in need?

$50

$100

$200

$300

$400

Other:

Can you help people fill out forms for government assistance and unemployment?

Yes

Clear selection

Can you provide legal support?

Yes

Clear selection

We are using WhatsApp to form local neighborhood groups, are you willing to learn how to use it and would you be interested in forming one for your block or neighborhood?

Yes

Other:

Clear selection

Any additional specifications, comments, or questions?

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