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2. Organization Name*
4. What services are you offering? What distribution method is being used?*
6. Contact Name*
7. Contact Email Address*
9. Organization Address
11. City
12. State
13. Zip Code
15. Contact Phone Number*
16. Organization Website
18. Hours of Operation
20. What are the primary populations that your organizations serves that may be disproportionately impacted by the COVID-19 crisis?*

    1. All Populations
    2. Communities of Color
    3. Incarcerated or detained populations
    4. Individuals experiencing homelessness
    5. Individuals experiencing domestic violence
    6. Individuals with disabilities
    7. LGBTQ+
    8. Low-income individuals/families
    9. Populations experiencing hunger, food, or nutrition insecurity
    10. Mountain community populations
    11. Seniors
    12. Undocumented populations
    13. Uninsured populations
    14. Children under 18
    15. People whose native language is not English or with low English language proficiency
22. Do you provide any services in languages other than English? If so, which services and in what languages are they provided?*
24. Are walk-ins accepted or do you need an appointment?

    1. Walk-ins accepted but appointment is preferred
    2. Walk-ins accepted
    3. Appointment only
26. Is this service free or at cost? Please include cost in your answer.*
28. What supplies or material resources does your organization need?*

    1. Self-stable Food
    2. Fresh Food
    3. Frozen Food
    4. Cardboard boxes/bags for distribution
    5. Safety Supplies (disinfectant, gloves, etc.)
    6. Transportation
    7. Volunteers
    8. None
30. Any other information you would like us to know?
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32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

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