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* 1. What is your First and Last Name?

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* 2. What is the best telephone number to call or text you?

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* 3. What is your email?

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* 5. What are the critical issues you need help with during the COVID-19 emergency?

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* 7. Do you have a child who gets free lunch in the home?

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* 8. What are some critical needs that you have right now as a result of the COVID-19 Emergency?

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* 9. Do you have a caregiver?

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* 10. Do you need a caregiver?

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* 11. Do you need technology to assist you in your daily living?

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* 12. How can our organization assist you in your time of need during this emergency?

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