Contact information and Assistance details
Registration form for people self-isolating due to COVID-19.
This form can be filled in by an individual as self referral, or a sevadar may fill this in on behalf of the service user.
Sign in to Google to save your progress. Learn more
What is your full name? *
What is your address? *
Include door number, street, area and POSTCODE
What is your phone number? *
Mobile or Landline (mobile preferred)
What is your email address (if available)?
What are your Secondary Emergency contact details?
Name, number (at least)
What is your Age?
Do you have any high risk health conditions?
e.g. instructed to get flu jab, asthma, COPD, emphysema, bronchitis, heart disease, kidney disease, liver disease, parkinsons, motor neurone disease, diabetes, weakened immune system, seriously overweight, pregnant
Are you classified as a High Risk individual?
Clear selection
Please list if you have any food or other allergies?
What medications do you take?
This enables us to check up on your safety.
Required Services *
e.g adult diapers, menstrual products, food, cleaning, medical, toiletries etc. Or shopping/medication pick up and drop off. Or some phone check in service.
Required
Essential Shopping Items
If shopping is required, please fill in what essential items you need. Please note that this must be paid for by the service user, and the team will make an assessment on your request. Please include how often shopping is required.
How many hot meals would you like delivered on THURSDAY?
We deliver hot meals two times a week on Thursday and Sunday. The food can be stored in the fridge to last multiple days. Please include how many meals you would like delivered on a THURSDAY. (We aim to get meals delivered between 1PM - 3PM) The contents of the langar meal may vary but will always be fresh and vegetarian.
Clear selection
How many hot meals would you like delivered on SUNDAY?
We deliver hot meals two times a week on Thursday and Sunday. The food can be stored in the fridge to last multiple days. Please include how many meals you would like delivered on a SUNDAY. (We aim to get meals delivered between 1PM - 3PM) The contents of the langar meal may vary but will always be fresh and vegetarian.
Clear selection
Sevadar/Volunteer Assigned
Leave blank unless you are in the Admin team
Any Additional Notes
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
Google Forms