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* 1. Would you be willing to pair up with another family that may need assistance during the current Covid-19 social distancing environment?

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* 2. How many families would you be willing to partner with?

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* 3. Is someone in your household at high risk if Covid-19 is contracted due to age, heart or lung disease, other?  How many?

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* 4. What special needs do you think you might have?

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* 5. Please leave your name and contact Number

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