YIS COVID-19 Needs Assessment
The purpose of this form is to collect information about you and how you have been affected by the pandemic. All responses are confidential.
To be eligible for assistance, you should be
18 to 24 years old, low to moderate income, identify as LGBTQ+
and have been impacted disproportionately by the COVID-19 pandemic.
Date of Birth
Race/Ethnicity: Select the following that apply to you
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
Other Race/Ethnicity or Multiple
Gender Identity/Sexual Orientation: Select the following that apply to you