COVID-19 Help Request Form

The San Miguel County community has come together during this COVID-19 crisis. We will try to help you or direct you to appropriate resources as best as we can.  If this is an emergency, please call 911 for assistance.

Please note that fields marked with an asterisk (*) are required.

Client Information

Emergency Contact

Environment and Mobility

YesNo

YesNo

Assistance Requested

Recipient of Volunteer Service Waiver

San Miguel County and Tri-County Health Network does not assume liability for individuals, groups, organizations, businesses, or others who provide volunteer services or programs sponsored or organized, in part or whole, by either entity.

In consideration for your participation in any services/program(s) sponsored, in part or whole, by either entity, the undersigned individual, group, organization, business, spectator, or other, does hereby release and forever discharge either entity and its officers, boards, volunteers, vendors, sponsors, partnering organizations and employees, jointly and severally from any and all actions, causes of actions, claims and demands for, upon or by reason of any damage, loss or injury, which hereafter may be sustained as a result.

This release extends and applies to, and also covers and includes, all unknown, unforeseen, unanticipated and unsuspected injuries, damages, loss and liability and the consequences thereof, as well as those now disclosed and known to exit. The provisions of any state, federal, local or territorial law or state providing substance that releases shall not extend to claims, demands, injuries, or damages which are known or unsuspected to exist at this time, to the person executing such release, they are hereby expressly waived.

I hereby agree on behalf of my heirs, executors, administrators, and assigns, to indemnify either entity. and its officers, boards and employees, jointly and severally from any and all actions, causes of actions, claims and demands for, upon or by reason of any damage, loss or injury, which hereafter may be sustained by participating in programs administered, in part or in whole, by either entity.

Electronic Signature Agreement: The parties agree that this agreement may be electronically signed. The parties acknowledge that electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.

If you get a message that says, “There was an error trying to send your message. Please try again later,” just click “Submit” again.

If you continue to get an error message, please call (704.236.4425) M-F 8 -5 for assistance.

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