Name *

First Name

Last Name

Gender *

Female

Male

Age *

18-25

26-40

41-59

60+

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you currently isolated? *

Yes, I live alone and am unable to leave my home

Yes, I live with family and am unable to leave my home

Yes, I live in a shared housing arrangement with roommates and unable to leave my home

No, I am able to leave my home to do essential work or run necessary errands

Please tell us about the assistance you need. *

I am isolated and would appreciate a phone call

I would like help connecting to First Prez's online services and digital resources

I need help picking up groceries

I need help picking up prescription medication

I need help with an errand or other specific need (please share some of the details below)

If you would like someone to contact you who will patiently help you connect to the online resources of our church, please select the kind of computer, tablet or phone you would like help with.

Apple iPhone or iPad

Android Phone or Tablet

MacOs Computer

PC Computer

Other

Which First Prez or The Vine worship service do you attend? *

8:00 AM at Ko'olau

10:00 AM at Ko'olau

10:00 AM at The Vine

I've just started attending First Prez | The Vine

I don't currently attend First Prez | The Vine

How did you hear about this ministry at First Prez | The Vine? *

First Prez | The Vine website

Email from the church

A friend told me

Social media

Other

About Your Information *

We will only use your details to put you in contact with one of our volunteers. We will do our best to ensure your information remains secure. By checking this box, you acknowledge you are happy for us to share your details with one of our volunteer team members.

Yes, I have read, understand and agree with this statement.