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 alcohol or drugs, medicinal or otherwise, on the premises, adjacent properties, and within 4 blocks
3.  No weapons of any kind are allowed at the distro
4. Do not be disrespectful or disruptive, no hate speech of any kind will be tolerated. We reserve the right to ask you to leave in order to ensure the safety of our community
5. Take only what you need and please let us know if there’s anything else we can do to meet your basic needs
6. Please do not stay at the UU or our neighbor’s buildings after the distro is complete at 12:30 pm
7. Only volunteers are allowed inside the UU building and on the sidewalk behind our partner tents during the distro event
8.  

   Distro Line Questionnaire 2023

   • Name (initials are acceptable)
     First Last
   • Email (OR)
   • Phone (in case we need to contact for food recall)
   • How many people in your household?*
   • Where do you call home?
     • House/Apartment/Condo
     • Mobile Home
     • Tent/Camping
     • RV
     • Car
     • Unsheltered/Unhoused
     • Couch Surfing
     • Hotel/Motel
   • Do you use a kitchen regularly/daily?
     • Yes
     • No
   • Zip Code
   • Do you have low income or NO income?*
     • Yes
     • No

   • 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.
   • Are you a veteran?
     • Yes
     • No
   • What is your age?
     • Under 18
     • 18 - 24
     • 25 - 44
     • 45 -54
     • 55 - 64
     • 65 or older
   • What is your race/ethnicity?
     • American Indian, Native American, Native Hawaiian, or Alaska Native
     • Arab American or Middle Eastern
     • Asian, Asian American, or Pacific Islander
     • Black or African American
     • Latino/a, Latinx, Hispanic, or Spanish
     • White or Caucasian
     • Multiracial
   • Which gender do you identify as?
     • Female
     • Male
     • Non-Binary / Nonconforming
     • Transgender
     • Prefer Not To Say
   • Interested in other essential services?
     Check all that apply
     • Select All
     • Dog & Cat Vaccinations
     • Hair Cut
     • Veteran Services
     • Personal Identification Assistance
     • Street Outreach (sleeping bags, tents)
     • Mental Health Support
     • Other? (add to notes below)
   • Notes
     Any important notes for this community member?