WPV CARES Request WPV CARES Request Form WPV CARES Emergency Response Program Request Form Name of Person Filling Out Form* First Last Phone*Email Is this request for yourself or someone else?This request is for myself.This request is for someone else.If for someone else, whom?*Family MemberFriend/NeighborIs this person over 65 years of age and/or at higher risk for contracting the coronavius?*YES, the person is over 65 years oldNO, the person is not over 65, but is at risk of contracting the coronavirusNO, 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 belowHow 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 belowEmailThis field is for validation purposes and should be left unchanged.