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**THIS FORM IS NO LONGER IN USE. If you landed on this page, please email stlquarantine@gmail.com.** STL Quarantine Support - Request Form
**THIS FORM IS NO LONGER IN USE. If you landed on this page, please email stlquarantine@gmail.com.**
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* Indicates required question
Have you filled out the Intake Form?
*
Yes
No
Note: If you haven't filled out the intake form, please follow the link below and fill out that form before continuing here.
https://tinyurl.com/STLQSintake
What do you need picked up for you?
*
Groceries
Medication
Other:
Required
Location of Pharmacy if requesting medication:
Your answer
Please give any information needed to pick up your prescription including date of birth (MM/DD/YY):
Your answer
Grocery items to pick up: (Please include sizes, brands, etc.)
Your answer
What is your estimated cost?
*
Your answer
Do you have enough money to cover this request? (Note: we accept PayPal and Venmo transfers, checks, and EBT!) **FYI we are grassroots funded; at this time we do not have enough funding to donate bags of groceries.**
*
Yes
No
If you are able to pay, have you sent the money to our PayPal account? (Link:
https://www.paypal.me/stlquarantinesupport
)
Yes
No
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Delivery instructions:
Your answer
Note: Volunteers will shop at Schnucks stores unless otherwise directed. Your volunteer will communicate with you if any items are not available to talk about substitutions, etc.
First Name
*
Your answer
Last Name
*
Your answer
Best Phone Number
*
Your answer
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