Culter/CBM Resilience COVID-19 :  Registration of persons at increased risk
The information collected via this form will allow the resilience team to create a list of residents who may need assistance during this period.  If you complete this form, one of the volunteers will maintain contact with you on a regular basis.  In the event of the situation escalating, this information will be used to coordinate a community-based response.

All information supplied will be treated as confidential and will only be used by the Resilience Team.

If you are completing this form on behalf of someone else, please make sure you supply your details as well. (This will be done in section TWO, access to which is determined by the final question in this section.)

Make sure you click on the 'Submit' button when you have finished.  This is found on the next page.
Sign in to Google to save your progress. Learn more
Name(s) *
Please enter the names of all people who are at increased risk living at the same address.
In which Community Council area do you reside? *
Address *
Enter the full address, except the postcode.
Postcode *
Please use a single space between the two parts of the postcode (e.g. AB14 0UD)
Phone number(s) *
Please enter the preferred number first, followed by any others separated by commas.  (Enter 'None' if you do not have a phone.)
Email address
Key contact : name *
Please provide the name of a person we can contact if necessary. This should be a trusted relative or close friend.  Please make sure you have the permission of this person to supply these details.  (Enter 'None' if you cannot provide a key contact.)
Key contact : phone number(s) *
The phone number(s) for the key contact.  If more than one, separate with a comma.  (Enter 'None' if you cannot provide a key contact.)
Key contact : email address
The email address for the key contact.
Any other useful, relevant information
E.g. you require prescriptions to be collected etc.
Security word *
Please enter a word that can be used by the resilience team to confirm their identity to you.  The team member will use this word whenever they call you.  Do not enter a password that you use elsewhere.  It could be a name, a place - anything memorable.
Are you completing this form for yourself? *
If you are completing this for someone else, section 2 is where you enter your own details.
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms