Wells Coronavirus Network
Wells Coronavirus Network is a group of Wells-based Community Organisations who have decided to work together to help coordinate the community's response to COVID-19. We include the Connect Centre, Neighbourhood Watch, Sustainable Wells, Wells Community Notice Board Facebook page, Burcott Road Residents Association, Project Factory CIC and members of Wells City and Mendip District Councils.

Please use this form to let us know about the assistance you need now or may need in the future. We are helping groups of volunteers to coordinate and provide support to the community.

If you need emergency medical or health assistance - please don't hesitate to call 111 or suitable services such as Samaritans on 116 123
YOUR EMAIL ADDRESS *
Your answer
YOUR FIRST NAME *
Your answer
YOUR LAST NAME *
Your answer
Gender
YOUR AGE GROUP
YOUR PHONE NUMBER *
Your answer
YOUR STREET NAME & POSTCODE
Your answer
EMERGENCY CONTACT NAME AND NUMBER
Your answer
Name of your Doctors Surgery and GP
Your answer
Do you need support with any of the following? Please provide more details in the next questions
Do you have a preference for the gender of volunteer help you receive?
Please tell us more about the support you require?
Your answer
If you are already a member of a residents association, a neighbourhood watch group or other community organisation please state which one.
Your answer
Disclaimer Your Data
We may use the information you provide to contact you via email or phone for the sole purpose of responding to the current COVID-19 outbreak. You can let us know at any time if you wish your details to be removed from the database.We will not hold on to your information for longer than is necessary. cv19@connect-centre.org.uk

I agree my contact details may be shared with restricted third parties (e.g. doctors' surgery) to aid emergency response. * *
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