If you live in Montgomery or Rocky Hill in NJ and are at-risk and need assistance, please fill out the form below. Your information will be kept confidential. Name Name First Last Suffix Email Address Address Address Address 2 City/Town State/Province NJAlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Phone Birth Year Reason(s) At-risk Age Compromised Immune System Other Medical Condition Mobility Issues Other disability Other… Enter other… What needs do you have? (Check all that apply) Grocery Pickup and Delivery Medicine Pickup and Delivery Someone to call me every few days to check on me Transportation for medical appointment Referral for mental health services/intervention Help with affording food Assistance with Government Programs Help with technology/connectivity (such as a smartphone, tablet, laptop, etc.) Help with a pet Other… Enter other… Status message This form is for Montgomery and Rocky Hill residents who have a bona fide need as expressed on this form. This volunteer service is not a substitute for commercial delivery services. By submitting this form, you are certifying that your response on the form is accurate.