Home
Staff
Mutual Aid Programs
Volunteer
Donate
Contact
REQUEST AID
AID REQUEST FORM
*
Indicates required field
Name (First, Last)
*
Email
*
Phone Number (cell preferred)
*
Have you already contacted 211 Community Connect for assistance? If not, we highly recommend dialing '211' and getting connected with additional resources (including housing + financial assistance).
*
Yes
No
Do you live in the 92501 or 92507 area code? (These are currently the only areas we service)
*
What Riverside neighborhood do you live in?
*
Do you have reliable transportation?
*
Yes
No
Are you over the age of 60?
*
Yes
No
Do you have a chronic health condition that affects your immune system?
*
Yes
No
Have you had fever or flu-like symptoms in the last week?
*
Yes
No
I am seeking assistance with... (please select all that apply)
*
Meal Assistance
Virtual Wellbeing Check (Wednesdays 12pm-3pm)
Hygiene/Medical Donations
How did you hear about us?
*
Facebook
Instagram
Referred by friend/co-worker
Referred by social services agency
Google Search
Other
Are there any other support options that you think we should offer that aren't on the list above? If none, please write 'N/A' in the response below.
*
Anything else we should know? [Optional]
*
Please note, we are currently experiencing high volumes of aid requests. We will notify you by email if we are unable to complete your request at this time. We appreciate your patience as our volunteers work hard to fulfill your aid request
Submit
Artwork by @amorysolecito_art
Home
Staff
Mutual Aid Programs
Volunteer
Donate
Contact