COVID-19 Community Support Request
Gosport Voluntary Action and Gosport Borough Council are coordinating the Gosport community response in relation to the Coronavirus (COVID-19) situation.

If you are currently isolated at home and are older/vulnerable or have a disability and need some practical support, please complete this request form.

PLEASE ONLY COMPLETE THIS FORM IF YOU HAVE NO OTHER OPTION FOR RECEIVING SUPPORT. If you're able to, please view the local update on our website to see if you can order food from local delivery services in the first instance.  https://www.gva.org.uk/coronavirus/local-updates/ 

The purpose of this form is to collect your contact details and the kind of support you need, so we can try to help connect you to support in the community.

If you need help with this form, please call the Gosport Community Helpline on 023 9254 5588. Lines are open Monday to Friday 9am to 5pm.

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Full name *
Address *
Postcode *
Phone number *
Email address
Age *
Please answer yes or no to the following: *
Yes
No
Do you have underlying health conditions?
Do you live alone?
Do you have children under the age of 18 in the household?
Do you have any allergies?
Are you receiving support from social services?
What do you need help with? *
Required
Have you received a letter or text message from the NHS telling you to stay at home for 12 weeks, known as shielding? *
If you live in social housing, who is your landlord?
Are you filling in this form yourself? *
If no, and someone else is filling this form in, please provide details below
Please detail below any other notes or comments that may help us assess your need or give us any other relevant information
Please read before submitting
By submitting this form, you are agreeing to your details being shared with local community groups, Council services and its health partners, so that we can help support as part of the Coronavirus response. The legal basis for this use is your consent. Your information will not be used for any other purpose and will be removed when the Coronavirus response is complete, or when you withdraw your consent. You can withdraw this consent at any time by contacting mail@gva.org.uk or phoning 02392 583836, and Gosport Voluntary Action will remove your data and inform other providers to do so. Our full privacy statement giving your rights is online, or ask us for an accessible copy.
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