Get Help - Covid-19 Support

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* 1. I consent for the United Way Centraide North East Ontario to share my contact information as provided with area supports to respond to the needs I am identifying below:

Yes

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* 2. I require assistance with the following (check all that apply)

Grocery Delivery

Prescription Pick Up and Delivery

I would like someone to talk to/Social Support

Info on Services Available

Require Access to a Food Bank

Other (please specify)

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* 3. Please select your current age range:

39 or Under

40 to 54

55 to 64

65 to 79

80+

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* 4. Do you have any mobility issues?

Yes

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* 5. Do you have any of the following health symptoms? (check all that apply)

Fever (greater or equal to 38°C)

Cough

Difficulty Breathing

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* 6. My Contact Information

Name

Address

Address 2

City/Town

Province

Postal Code

Email Address

Phone Number

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* 7. The best way for someone to reach me

Phone

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* 8. Please share anything else we should know about your current situation

Please note that UWCNEO will never request or collect your personal financial or banking information. If you suspect fraud, immediately call the Canadian Anti-Fraud Centre at 1-888-495-8501.