Preferred Language *
— English Spanish Other
Environment and Mobility
Who do you live with? (Select all that apply)
— Spouse/Significant Other Parents Children Roommates No One
What type of health insurance do you have? (Select all that apply) *
— Private Medicaid Medicare VA (Veterans Affairs) Uninsured
Please select all services and resources your household needs. (Select all that apply. For Windows, hold down the Ctrl button as you select multiple options. For Mac, use Cmd button.) *
— Financial support Emotional Support Medical/Physical Support Housing Food Transportation Petcare Childcare and infant supplies Translation services Errands (mail, prescriptions, groceries, snow shoveling, firewood stacking)
What are your emotional support needs? (Select all that apply)
— Needs help paying for mental or behavioral health services Needs a companion Needs caregiver support Needs insurance Needs domestic violence resources
What are your medical or physical needs? (Select all that apply)
— Needs companion to medical appointment Needs durable medical equipment (wheelchair, cane, etc.) Needs prescription pick-up Needs transportation Alzheimer's & Dementia support Home health or hospice
What are your housing needs? (Select all that apply)
— I am homeless Need housing application assistance Need help paying rent Need help paying mortage Need help paying utilities Need firewood Need heating repair Need handyman work (leaky pipes, pest infestation etc.) Need mold mitigation
What are your food assistance needs? (Select all that apply)
— Need help with SNAP application (food stamps) Need someone to shop for me Need meals prepared for me Need groceries delivered Need food box delivered Need WIC resources Need assistance buying formula and baby food
What are your transportation needs? (Select all that apply)
— Need transportation to Senior Meals Need transportation to medical appointments Need transportation to store, bank, post office, etc. Need transportation to Montrose, Grand Junction, or Durango Need help paying for car repairs Other
What are your petcare needs? (Select all that apply)
— Need dog-walking Need pet-sitting
What are your childcare and infant supply needs? (Select all that apply)
— Need tutoring Need help paying for childcare Need a childcare provider Need help paying for diapers Need assistance buying formula and baby food
What errands or tasks do you need done? (Select all that apply)
— Need prescription pick-up Need snow shoveling Need yard maintenance Need assistance with firewood (chopping, stacking, etc.) Need grocery pick-up Need mail pick-up
Why do you need assistance with these tasks and/or errands? (Select all that apply.)
— Chronic illness Acute illness Injury COVID19 quarantine Over 60 or disabled
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.
(or parent/guardian if less than 18) * (Use your mouse or trackpad to sign.)
Relationship to Client (if less than 18) *