COVID-19 Impacted Assistance

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COVID-19 Impacted Assistance - ACSNC

At Azerbaijan Cultural Society (ACSNC) we are committed in taking care of our community members, and in this time we need all of our community to come together and take care of those in need.

If you are impacted by the COVID-19 and are in need of assistance, please fill out this form and we will reach out to you.

If you have any questions, please email us at secretary@acsnc.org

Name

How can we best contact you? ( Please include your phone number or email! ) *

Where are you located? *

Do you have reliable transportation? (not required) *

Yes

Other:

Are you over the age of 60? *

Yes

Other:

Do you have a chronic health condition that affects your immune system? *

Yes

Have you had fever or flu like symptoms in the last week? *

Yes

I am seeking assistance with... *

Picking up and delivering groceries, medicine, or other essentials

Transportation to medical facilities (to avoid public transit/ride shares)

Cleaning supplies or essential items while out of work / income reduced

Meals

1 on 1 phone calls /Zoom - video chats

Assistance navigating and advocating to social services

Financial assistance

Did you lose your job and need job search assistance?

Other:

Required

Anything else we should know?

Submit

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