Mutual Aid Beacon Request Form

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Are you in the Beacon / Fishkill / Wappingers Falls (NY) area and in need of support?

You can this form to let Mutual Aid Beacon know what you need. You can also call/text us at 845.288.2559 or send an email to mutualaidbeacon@gmail.com.

We are an all-volunteer grassroots group. We review requests every day, and will get back to you as soon as we can. Thank you for your patience and grace.

You can learn more about us on our website - beaconmutualaid.com.

Thanks for being committed to taking care of each other.
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First name* This field is required.
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Last name* This field is required.
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Which pronouns do you use?
she/her/hers
he/him/his
they/them/theirs
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Email* This field is required.
example@example.com
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Phone number* This field is required.
Area Code
Phone Number
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Can you receive text messages at this phone number?* This field is required.
yes
no
preferred
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What is your address?* This field is required.
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If you would prefer to communicate with Mutual Aid Beacon in a language other than English, which language would be best?Skip if English is your preferred language
Spanish
French
Italian
Korean
ASL
Other
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Are you over the age of 60?* This field is required.
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Do you have a chronic health condition that affects your immune system?If so, describe here. If not, leave blank.
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Have you had a fever or flu-like symptoms in the past week?* This field is required.If you know your COVID-19 status (e.g., positive COVID-19 test, previously symptomatic and recovered, positive antibody test), let us know. This information will not be shared.
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What kind of assistance are you looking for?* This field is required.Choose as many as apply to you
I need for someone to go shopping for me
I need for someone to pick up a prescription from my pharmacy
I have trouble cooking for myself and am looking for meal delivery (prepared, easy to reheat)
I need help getting to a doctor's appointment
I think I'd like someone to talk to
I want to get on the list for weekly, free grocery delivery
I'd like for someone to check in on my elderly/disabled friend/relative in the area
I can't get my technology to work right (e.g., Internet, FaceTime, Zoom, etc.)
I need for someone to help me navigate social or medical services (e.g., doctors appointments, prescription refills, etc.)
I need for someone to help resolve a conflict with a neighbor/relative
I need help that isn't listed here, but I'll explain below
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Because you requested weekly free grocery deliveries...

Several local food justice organizations are working together to get food to neighbors in need due to the COVID-19 pandemic. Mutual Aid Beacon currently delivers groceries to our neighbors on Fridays. Give us your information here, and we will add you to the waiting list for the next available opening for free grocery deliveries. A volunteer will contact you as soon as your household is added to an active delivery list.
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RE: Shopping requests - Please provide your shopping list here* This field is required.Items can be general like "milk," or specific like "a 24-pack of the purple Always brand overnight menstrual pads with wings." A shopper will do their best to match your requests, but if they can't find something specific you will receive a substitute (unless you say otherwise). You are trusted to know your needs and we are committed to delivery without judgment.
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Are you able to pay for the groceries or supplies you need?* This field is required.Mutual Aid Beacon is committed to providing help to members of our community, regardless of ability to pay, to the extent that we are able. Your answer to this question will not affect Mutual Aid Beacon's response.
YESNO
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Thank you for letting us know you are able to pay for the groceries or supplies a Mutual Aid Beacon volunteer may get for you. We ask that those who can pay make a contribution to the Mutual Aid Beacon common resource fund through our Venmo account - venmo.com/MutualAidBeacon.

We use this fund to support requests from neighbors who - for whatever reason - are unable to pay for essentials like food, cleaning supplies, etc.

If you do not have Venmo, we can discuss other ways to contribute.
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RE: Prepared Meal requests - Do you have a permanent need for prepared meal support, or are you only temporarily unable to prepare meals?* This field is required.
Permanent
Temporary
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Tell us a little bit more about why you need prepared meal support.* This field is required.If this is a temporary request, please let us know how long your hoping to have prepared meal support.
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What dietary restrictions, allergies, or intolerances do you have that we should know about?* This field is required.Halal, kosher, vegetarian, vegan, allergic to peanuts, lactose intolerant, gluten-free, scent sensitive, etc -- this is important in case we're trying to substitute "our best guess for what you'd like" in place of "something you asked for" that's not available. Please don't leave this blank. If there are no restrictions, write "no restrictions" in the space below.
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How many people are in your household?* This field is required.
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RE: Prescription Pickup - Is the prescription paid for and ready for pickup now?* This field is required.All prescriptions must be paid for and ready for pickup before a Mutual Aid Beacon volunteer can help.
YESNO
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When will your prescription be paid for and ready for pickup?* This field is required.
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What is your pharmacy?* This field is required.Provide the name and address of your pharmacy. Pharmacy must be in Beacon, Fishkill, or Wappingers Falls.
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Full name and date of birth for the prescription recipient* This field is required.Pharmacies require this information for prescription pickup.
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Is there anything we need to know about delivering to your home?Our volunteers will attempt to call or text before every delivery. Let us know if there is anything that would help make delivery to you easier (e.g., yellow house off street, leave on back porch, small dog inside will bark a lot).
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RE: Transportation to Appointments - What is the date and time of your appointment?* This field is required.
Date
Year
Month
Day
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8
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Hour
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30
40
50
Minutes
AM
AM
PM
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What is the address for the medical office you are going to?* This field is required.
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Where will the driver pick you up (if not your home address)?* This field is required.
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Is there any special information the driver would need to find you?* This field is required.
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RE: Checking in on a neighbor - Who would you like for a Mutual Aid Beacon volunteer to check in with, and why?* This field is required.
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Where is this neighbor located?* This field is required.
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What is this person's phone number?* This field is required.
Area Code
Phone Number
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What is your relationship with this person?* This field is required.
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Is there anything we need to know about this neighbor to ensure a safe and welcome contact?
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Would you like for us to give you an update on your friend/relative after the call/visit?* This field is required.We will ask the neighbor's permission to do this, and will only provide detailed information if permission is granted.
YESNO
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Since you requested connection support (e.g., tech support, conflict resolution, personal check-in)

A Mutual Aid Beacon connections support volunteer will be in touch with you within the next few days to find out more about how we can help you.
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What kind of support are you looking for that wasn't listed above?* This field is required.
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Is there anything else you would like us to know?
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By submitting this form to receive voluntary services, you agree that you would like to be contacted by Mutual Aid Beacon dispatchers and/or other volunteers about your request. You accept all risk and responsibility including any injury or harms that may result from receiving services, and further hold any facilitator associated with Mutual Aid Beacon harmless. You agree to follow Mutual Aid Beacon’s General Safety Protocols and all rules and orders of government health authorities. You understand that Mutual Aid Beacon volunteers are not healthcare professionals. If you need medical advice, you will call your physician or 911.
Should be Empty:

Because you requested weekly free grocery deliveries...

Since you requested connection support (e.g., tech support, conflict resolution, personal check-in)

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