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Connel Community Council COVID-19 Request for Support Sign-Up Form
Form to enter request for support for Connel Community Council Area
See our Privacy Notice here (
https://docs.google.com/document/d/1O9Mf4nsZF4Q1kLyMX2kBt6TJyxRfp-RftlDe5OBmQjo/edit?usp=sharing
)
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* Indicates required question
Email
*
Your email
Name (What you want to be called?)
*
Your answer
Please add your phone number below so we can connect you with a support volunteer
*
Your answer
Name or Number of House
*
Your answer
Postcode
*
Your answer
What support do you require?
*
Arranging Deliveries
Picking up shopping, urgent supplies and medication
A Friendly Phone Call
Posting Mail
Help Topping up Electric or Gas Key
Food preparation
Looking after pets (e.g. Dog walking)
Health advice / check in
Emotional support / advice
Other advice /care
Other:
Required
If you need supplies, how can you pay? (Tick Any)
PayPal
Bank Transfer
Cash
Other:
Data agreement - By pressing submit, you consent to your details being shared with volunteers who will contact you and ask you questions about your needs, and arrange support. Please do not provide any sensitive details on this form that you would not wish to divulge. Our volunteers are asked to read and consent to our General Data Protection Notice.For further info, contact
connelcommunitycouncil@gmail.com
Your answer
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