COVID-19 Community Resource Form – Tri-County Health Network

San Miguel County asked Tri-County Health Network to oversee our county’s volunteer efforts during the COVID crisis. Tri County’s role is to maintain a community resource guide and to coordinate the volunteer project. We will try our best to match those in need with volunteers and appropriate resources. As such we are asking our local governments, non-profits, and other organizations to complete this form and share the services/resources you are providing during the stay-in-home order.

Please complete the following information for each program/service your organization is providing during the COVID-19 crisis. By providing current, accurate information we can help ensure community members get the help they need.

Questions? Contact Sami Damsky: volunteer@tchnetwork.or

General Information

Organization Name*

Primary Phone (Format: 123-456-7890)*

Primary Email*

Fax

Website

URLs for Specific Programs (if applicable)

Physical Address

Address Line 1*

Address Line 2

Address City*

Address State*

Address Zip Code*

Mailing Address (if different from above)

Mailing Address Line 1

Mailing Address Line 2

Mailing Address City

Mailing Address State

Mailing Address Zip Code

Service Description

Please provide a brief description of the services you are offering during the COVID-19 response, include any costs, requirements(income qualifications, age limits, location, etc) :*

County(s) where these services are availabe: (Select all that apply)*

If Other, please specify:

Contact Information for Accessing Services

This is the information community members will use to request/arrange access to your services.

Name*

Title*

Phone/Cell*

Email*

Hours

Hours of Operation*

After Hours Contact (Email/Phone)

Additional Information

Please provide any additional information you think is relevant

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 contact volunteer@tchnetwork.org M-F 8 -5 for assistance.