This pandemic has affected our older generation and we want to check in to see if they are ok. Are you or someone you know 65ish+ that could use some help? Please let us know and we'll be back in touch with how we may be able to help.
Name
*
First Name
Last Name
Email
*
example@example.com
Type a question
*
Grocery Shopping
Small Project at Home
Technology Assistance
Phone or Zoom Call to Connect
Just Needs a Breath of Fresh Air and That Could Involve a Special Delivery of Something to Brighten Their Day
Other
If You Need to Explain More Please Do So Here.
If This Request is Not for You We will Need More Details, See Below
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Submit
Should be Empty: