Assistance request form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Kia ora and hello,

This form has been set up by Auckland Locals to serve as a contact point for at-risk or self-isolating individuals. If you require any assistance of any kind please fill in below and we will put you in contact with a local volunteer to help you.

Stay safe,

Noho ora mai,

The COVID-19 Auckland self-isolation community help page:

https://www.facebook.com/covid19AucklandHelp

Below are some websites and numbers to call for information:

https://covid19.govt.nz/ (government website for information)
Healthline: 800 358 5453 (if you suspect infection)
Government helpline: 0800 779 997 (8am–1am, 7 days a week).

Name of person requesting help: *

Are you requesting help for yourself or someone else?

Myself

Someone else

Clear selection

Contact details of person needing help (phone number and email)? IF YOU ARE REQUESTING HELP FOR SOMEONE ELSE YOU NEED TO ENTER YOUR DETAILS HERE TOO

What kind of assistance is required?

Grocery Delivery (note: we cannot give you a food parcel, we can pick up one you have organised elsewhere)

Someone for a chat

Dog walking

Check ups

Minor errands

Other:

When is help needed?

Further details on help required. Please notify us of any specific language, cultural, health or disability requirements here.

Location. Suburb is sufficient, your assigned volunteer will contact for further details.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms