COVID Intake Form

To be eligible for Northern Nevada Center for Independent Living COVID-19 services, a person must have been affected by COVID-19 and/or the resulting economic shutdown. In order to document that you are eligible for these services, please answer the following:

My income has been affected by COVID-19 Required field

I was working until March 2020 and my hours have been cut

I was working until March 2020 and I have been furloughed

I was working until March 2020 and I have been laid off

Services requested Required field

Temporary Food Assistance Program

Emergency Eviction Relief Program

Personal Protective Equipment

Other

I can also use help with Required field

Consumer Signature Required field

Date Required field

Month

Day

Year

COVID Intake Form

COVID-19 Resources

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COVID Intake Form

COVID-19 Resources

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