Distro Line Questionnaire

[ Read this to the participant ]

By participating in the Mutual Aid Distro, giving your information for this form, and/or receiving the services offered, you are agreeing to abide by the following guidelines while you are at the event:

  1. Refrain from smoking on premises — both church property and library property– as well as the sidewalk in front of the food pantry and the alley, which is utilized as a vehicle byway– this is for your own safety
  2. Refrain from the use or sale of drugs on the premises and the adjacent properties within 4 blocks
  3. Please do not stay at the UU or our neighbor’s buildings after the distro is complete at 1pm
  4. Do not be disrespectful or disruptive, we reserve the right to ask you to leave in order to ensure the safety of our community
  5. Take only what you need but please let us know if there’s anything else we can do to meet your basic needs
  6. Only volunteers are allowed inside the UU building and on the sidewalk behind our partner tents during the distro

  • (within 6 ft for 15 minutes)
  • Body sores, fever or chills, cough, shortness of breath, fatigue, body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting, or diarrhea.
  • Optional, but please ask 🙂

    It is okay if participant chooses not to answer, but you can explain that we need this info to receive funding to support the distro.
  • Check all that apply
  • Make any important notes for this client