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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
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Name
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First
Last
Email
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Essential Services Needs
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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")
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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
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What counties are you serving? (select all that apply; if you serve all 23 counties, please check "Select All")
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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
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