Request Aid

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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

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Home
Staff
Mutual Aid Programs
Volunteer
Donate
Contact

REQUEST AID​

AID REQUEST FORM​

REQUEST AID

AID REQUEST FORM