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By MSU, for MS(you).

Well Wishes Program Submission Form

Welcome to our Well Wishes Program Initiative! Please fill out anything below that is pertaining to you. This is how we care for one another so always reach out because no concern is too small.

First & Last Name

Please provide your full first name and full last name.

Phone number/quickest contact info

This will only be used to follow up on this care request.

Are you submitting this for yourself or someone else?

For myself

For someone else

Name of the person you’d like us to check in on (if applicable)

Please provide their full first name and full last name.

Would you like this request to be anonymous to them? (if applicable)

Yes - please keep this anonymous

No - it's ok for them to know I submitted this

Would you like to add a personal note? (if applicable)

How can we best be here for you/them?

Meal & Essentials Support

How can we best be here for you/them?

A home-delivered meal

Groceries or snacks

Medicine pickup

Care/Appreciation Box

Untitled checkboxes field

Care box

Check in/Emotional Support

Untitled checkboxes field

Appreciation or encouragement note

A visit (by friend, brother/sister, board member, etc.)

Practical Help

Untitled checkboxes field

Errand assistance

None of the options above? Please clarify what care we can best support you with.

Please provide more information on what you would like your care to look like

Examples: What type of meal you would like? What medicine is needed? What item would you like to include in the care box? What errands do you need assistance with?

Any allergies we should be aware of?

Delivery Preferences

Delivered by Well Wishes coordinator

Well Wishes coordinator delivers it to you, but you deliver it to who you wanted to send it to

Delivered directly by MSU brother

Delivered directly by MSU sister

No delivery needed - check-in only

Location details/preferred delivery times

We will try our best to align with your schedule.

This space is all yours! Elaborate on any of the previous points or say something new. Feel free to share anything else that would help us support you thoughtfully. For any further questions, don't hesitate to text (562)-386-1666!