WPV CARES Request

Name of Person Filling Out Form*

First Last

Phone*

Email

Is this request for yourself or someone else?

If for someone else, whom?*

Family Member
Friend/Neighbor

Is this person over 65 years of age and/or at higher risk for contracting the coronavius?*

YES, the person is over 65 years old
NO, the person is not over 65, but is at risk of contracting the coronavirus
NO, the person is not over 65 or at risk and I understand they may not be a right fit for the WPV CARES Emergency Response Program.

WPV CARES is an emergency response program geared towards helping those most vulnerable to the coronavirus pandemic with the strictest limitations of being home-bound and unable to do services themselves. If the person is not an older adult and/or does not have any high-risk, then they may not be a best fit for the WPV CARES Emergency Response Program.

Date of Birth for Person Requesting Support

MM

DD

YYYY

Name of the person the request is for:

First Last

Please Provide the Zip Code of the person who is in need of help:

* Our service region includes the following communities: Westchester, Playa Vista, Playa Del Rey, Marina Del Rey, Mar Vista, Del Rey, Culver City, Ladera Heights, El Segundo, Manhattan Beach and some adjacent Westside Regions. If the person is located outside of these regions, this may limit you to virtual services.

What type of help is needed (check all that apply)?*

Courier Services or Contactless Delivery of Groceries and/or other essentials
Weekly Social Support Calls
Weekly CARES Packages
Online & Phone Activities
Limited Transportation to urgent medical appointments
Referral to other support (please specify below)
Other (please specify below)

If referral to other support or other, please specify below:

Please specify below

How did you hear about the WPV CARES Program?*

Newspaper
Social Media (Facebook, Nextdoor, etc)
Flyer Distribution
Partnering Organization
Word of Mouth / Friend (please specify)
Other (please describe below)

Please specify below

Name

This field is for validation purposes and should be left unchanged.

WPV CARES Request Form