COVID-19 Assistance Request Form
Title:*
Name (With Middle Initial):*
Age:*
Status:*
Spouse Name:
Do you have children in your home?*
 Yes
 No
Age(s) of children in your home (mark all that apply):
 0-5
 6-10
 11-13
 14-18
 19-23
Home Phone:*
Cell Phone:
Primary Email:*
May we email you?(Email addresses are confidential and will not be spammed)*
 Yes
 No
May we text you?(Cell phone numbers are confidential and will not be abused)*
 Yes
 No
I or my immediately family:*
 Are CURRENTLY quarantined due to a COVID-19 exposure
 HAVE PREVIOUSLY BEEN quarantined for COVID-19 exposure but are no longer
 HAVE NEVER BEEN quarantined for COVID-19 exposure
I am in need of assistance due to the impact of COVID-19 in the following ways: (Check all that apply)*
 Grocery Delivery
 Prescription Delivery
 Meal Delivery
 Everyday Items Delivery
 Online Education Assistance
 Groceries
 Meals
 Financial
 Yard Work
 Basic Outdoor Home Repair
 Counseling
 Emotional Support
 Spiritual Guidance
 Medical Guidance
Prayer Requests:
Other Comments:
Thank you for reaching out to us at Earlington First Baptist. Once we have received your need request, someone will be in touch with you by phone, text, or email as soon as possible. If you would like an email confirmation of your request, please enter your email below.


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