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Request Aid
Please fill in the form below to request aid. Please do not combine entries but enter them separately if needing to request aid for more than one person.
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Email
*
Your email
Resident First Name
*
Your answer
Resident Surname
*
Your answer
House number or name
*
Your answer
Road/Street
*
Your answer
Post code
*
Your answer
Phone number
*
Your answer
How can we help?
*
Please select those that you wish to have help with. If you would like further information on the types of support we offer please visit our website:
Community Hot Meals Support
Wellbeing Support
Medical Transport Support
Emergency Essentials Support (Food Shopping/Prescription Collection)
Financial Impact Support
Home Support
Other Navigator Support
Technology Support (Device Loans)
Required
Additional Information
Please include any details that you believe relevant to your request. I.e. why the support is needed, any wellbeing and health information and amy special requests.
Your answer
Alternative Contact Information
If you are requesting support on behalf of someone else please leave your details here: Name, contact details and relationship to resident.
Your answer
By clicking submit you agree and consent for your data to be stored and used by Clevedon Aid and trusted partners. You can ask for it to be deleted at any time.
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A copy of your responses will be emailed to the address you provided.
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