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SE Como Request for Support
This form will be used to match support requests to volunteers offering support. The results from this form will remain confidential and may be used to inform programs and services during SECIA's response to COVID-19.
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What is your name and preferred pronouns?
Your answer
Please provide your phone number (Is texting okay?)
Your answer
Please provide your e-mail address
Your answer
Are you interested in staying up to date on programs and services offered by SECIA and around the neighborhood, by receiving our bi-weekly newsletter?
Yes
No
Clear selection
What kind of support are you looking for? (Check all that apply)
Food - I am looking for someone to deliver groceries
Supplies - I'm looking for basic supplies (hand sanitizer, paper products, etc)
Appointments - I am looking for someone to bring me to and from appointments
Dog - I have a dog that needs walking
Talk - I'm looking for someone to chat with via phone, e-mail, or video
Financial Support - I'm looking for financial relief (please provide more detail below so we can direct you to the best resource)
Other:
If you're seeking financial relief, please provide more detail so we can direct you to the best resource
Your answer
Any additional resources or requests we didn't think of
Your answer
Who are we reaching?
The following questions will help us understand who we are reaching, they are completely optional will not be used to determine the matching of support to those who need it.
Are you affiliated with the U of M?
I am a student
I am an employee/staff/faculty member
I am not affiliated with the U of M
Clear selection
What best describes your age?
under 18 years old
18 - 24 years old
25 - 34 years old
35 - 60 years old
60 years or older
Clear selection
Do you identify as Spanish, Hispanic, or Latinx?
I identify as Spanish
I identify as Hispanic
I identify as Latinx
I do not identify as Spanish, Hispanic, or Latinx
Clear selection
How would you describe yourself? (Check all that apply)
African American
Native American
Asian
White
Other:
Where did you find this survey?
Flyer in the neighborhood
Newsletter
Social media
Other:
Clear selection
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