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COVID-19 Community Needs Survey

The Town of Bethany is gathering information for any residents with needs during the COVID-19 epidemic. Because this disease most seriously effects seniors and those with health conditions we have designed this form to be filled not just for yourself but for anyone you believe may need help.

A local Bethany official will contact all names on this list by phone or email to ask those individuals what their needs may be. If that individual doesn't wish to be contacted further they will be removed from the list. This information will not be distributed outside of the town government or sold. Once we can assess what services are most in need we will do our best to work with the community to help. This could be anything from a daily check-in phone call to organizing supply drop offs.

Your name or the name of a Bethany resident who may have needs at this time

Please let us know your name.

 

Phone number and / or email for the person listed above

Please enter your phone number

Please let us know your email address.

 

Description of potential needs during this outbreak.

Please enter text