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Agency response form
We want to hear from you! Help us create a community informed plan on how to deploy these resources effectively and efficiently.
Organization Name
*
Name
*
First
Last
Email
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Essential Services Needs
*
What essential services needs have you identified and can provide as part of the COVID 19 response efforts?
Please keep responses to 3-5 sentences/bullets
Challenges or Gaps
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What challenges or gaps are you facing to deliver those services?
Please keep responses to 3-5 sentences/bullets
Populations
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What population are you serving? (select all that apply; if all apply, check "Select All")
Select All
Children ages 0-5 years
Children ages 6-12 years
Youth ages 13-18 years
Youth ages 19-25 years
Adults ages 25-59 years
Seniors ages 60+
Families with young children
Families with children receiving free and reduced lunch
Individuals/families without health insurance
Vulnerable workers (hourly workers, workers in the hospitality, service and gig economy industries) and their families
Other
Other Population
Counties
*
What counties are you serving? (select all that apply; if you serve all 23 counties, please check "Select All")
Select All
Barrow
Bartow
Butts
Carroll
Cherokee
City of Atlanta
Clayton
Cobb
Coweta
DeKalb
Douglas
Fayette
Forsyth
Fulton
Gwinnett
Hall
Henry
Morgan
Newton
Paulding
Pickens
Rockdale
Spalding
Walton
Name
This field is for validation purposes and should be left unchanged.
