Townsend Neighborhood Social and Services Group COVID-19 Impact Form

The Town of Townsend is working with a newly established citizen group- The Neighborhood Social and Services Group- to compile a list of residents who may be facing serious challenges during the COVID-19 Pandemic, in order to provide assistance to these residents and connect them with helpful resources.  

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* 1. Name 

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* 2. Townsend Address

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* 3. Phone Number

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* 4. Email Address

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* 5. If you are submitting this form on behalf of someone else, please provide your information and your relationship to the resident you are submitting on behalf of.  Please include your Name, Relationship to person facing the challenge, Phone Number, and Email Address.  
(If this question does not apply to you, please skip to the next question)

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* 6. Please provide a brief statement of your unmet needs:

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* 7. How has the COVID-19 Pandemic impacted you and created these unmet needs?

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* 8. Do you give permission to the Town of Townsend to share your information and needs with the Townsend Neighborhood Social and Services Group and/ or social services agencies in the area to provide you with any necessary assistance?

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