Name: *

First Name

Last Name

Do you want to be added to the HPC3 distribution list?

Yes

No

Name: *

First Name

Last Name

Are you offering a Resource or Requesting a Need? *

Housing, food, transportation, ride to an appointment, etc.

I am Offering a resource

I am Requesting a need

Both

If requesting assistance, what are your needs?

Housing

Transportation

Food

Need connection to doctors/Need medicine

Social support/Phone Calls

Storage

Pet

Childcare

Financial Support with Utilities, Rent, Etc.

Other:

If offering a resource, what can you offer?

Housing

Transportation

Food

Need connection to doctors/Need medicine

Social support/Phone Calls

Storage

Pet

Childcare

Financial Support

Other:

Are you in a risk category? *

Immunocompromised, chronic condition including asthma, hypertension, diabetes, etc

Yes

No

I'm unsure (let us know in the final question if you need help to figure this out)

Do any of the following apply to you? *

Please answer honestly. We will not ignore you based on your response to this. We just need to know so we can act accordingly.

I have COVID-19 symptoms (cough, fever, shortness of breath)

I am sick in some other way (cold, flu, anything)

In the last 2 weeks, I have traveled by plane

In the last 2 weeks, I have been in contact with someone who is now in quarantine

In the last 2 weeks, I have been in contact with someone who has COVID-19 symptoms

NONE of these apply to me