I may need help
This is the form to fill in if you are shielding and need assistance as a result of the COVID-19 Coronavirus epidemic. We can do your shopping, collect your prescription, cook you a meal, walk your dog, provide a buddy to chat to on the phone, we have a community library a friendship cafe and community fruit and veg market or just run an errand for you.

The information you provide in this form will only be used to help us deliver the services stated above. We will only share your data with relevant members of PCCA. Your data will not be shared or used for any other purposes without your consent.

If you change your mind later, please let us know by phoning 01672487022 and we can delete you from the list. All data will be deleted when it is no longer needed.

We are just neighbours looking out for each other. All our volunteers have been photo ID checked and most have provided proof of DBS . If you plan to let anyone you don’t know well into your home we strongly recommend you ask for proof of ID in the form of a PCCA photo ID Badge. PCCA will never ask to enter your property.

We are here to support our community.

Version 2.0
First Name *
Surname *
Address Line 1
Address Line 2
Date of Birth
Phone Number
How should we contact you? (Text, Phone, WhatsApp, Email)
Are you in a vulnerable group?
Clear selection
What help will you require?
If you need food, do you have any specific dietary requirements?
Agreement *
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