OFFER & REQUEST SUPPORT My Profile (Example): Full Name First Name Last Name Age: * City * State * Zip Code: * Country (if outside the U.S.) Phone #: (###) ### #### Email Address I would like to (you can offer AND request support if you want!): * Offer Support Request Support I would like to match with community members within ___ miles of my zip code: 1 mile 3 miles 5 miles 10 miles 20 miles Anywhere in my city/town! Primary Language: Additional languages: My Availability: Regular Schedule Variable...my schedule changes quite a bit IF REGULAR SCHEDULE (available days): Monday Tuesday Wednesday Thursday Friday Saturday Sunday IF REGULAR SCHEDULE (available times): Morning Afternoon Evening OFFER SUPPORT Level of Involvement Low (10-15 minute occasional tasks, online tasks) Medium (1-2 hours/month, online tasks) High (2+ hrs/week, online, required training) My Skills: Research/Finding Resources (e.g. access to healthcare, finding affordable childcare, looking up housing assistance programs, etc.) Social Support (e.g. supportive text messages, Facetiming someone that is isolated, etc.) Monetary Contributions (e.g. help pay for things that people need on a one-time or ongoing basis) Other_________________________ Age Group I want to support: Children/Families Adolescents Young Adults Adults Elderly My Interests (I would like to offer support with): Mental Health (e.g. finding mental health resources) Social Support (e.g supportive text messages, Facetime, etc.) Healthcare Access Physical Health Support (e.g. finding a physician or physical therapist) Nutrition (e.g. picking up groceries, applying for food stamps) Legal Support Immigration Physical Disabilities Intellectual/Developmental Disabilities Housing/Rent Affordability Transportation LGBTQ Rights Childcare Academic/School Support (K-12 & university) Adult/Elderly Caregiving Independent Living Skills Anything! Wherever I am needed Other Would you like to receive a weekly text/notification of people that might be a good fit for you? Yes No REQUEST SUPPORT I am requesting support for: Myself Child/Family Adolescent (12-17 years old) Young Adult (18-30 years old) Middle-Age Adults (31-65 years old) Older Adults (66+ years old) Level of Involvement Low (10-15 minute occasional tasks, online tasks) Medium (1-2 hours/month, online tasks) High (2+ hrs/week, online tasks) Primary topics I would like to request support with: Mental Health (e.g. finding mental health resources) Social Support (e.g supportive text messages, Facetime, etc.) Healthcare Access Physical Health Support (e.g. finding a physician or physical therapist) Nutrition (e.g. picking up groceries, applying for food stamps) Legal Support Immigration Physical Disabilities Intellectual/Developmental Disabilities Housing/Rent Affordability Transportation LGBTQ Rights Childcare Academic/School Support (K-12 & university) Adult/Elderly Caregiving Independent Living Skills Anything! Wherever I am needed Other Would you like to receive a weekly text/notification of people that might be a good fit for you? Yes No Thank you!
