Covid Information Connectors
By completing this form you are registering your interest in becoming a Covid Information Connector. All of your details will remain confidential and will only be accessed by South Derbyshire CVS. We may contact you to ask for further information and will keep you updated as the project develops. If successful, South Derbyshire CVS will send you a 'Covid Information Connector Code of Conduct' which we require you to agree to. We will then send you the latest Covid Information from the health authorities to circulate with your networks.
* Required
Name
*
Your answer
Age (if you prefer not to say please leave this section blank).
Your answer
Gender
Male
Female
Prefer not to say
Other:
Clear selection
Email
*
Your answer
Address
*
Your answer
Phone number
*
Your answer
Briefly, please tell us about the people you will share Covid Information with (For example: Who are they? Where do they live? How old are they?)
Your answer
Approximately, how many people will you be able to share Covid Information with?
Your answer
Briefly, please tell us why you think you would be a good Covid Information Connector.
Your answer
How would you share information with your connections? (you may select more than one option)
Social Media
Email
Telephone
Zoom/Microsoft Teams
In person (with appropriate social distancing measures)
Printed Media (such as notice boards/leaflets etc)
Do you agree to the following code of conduct? (a separate copy will be sent to you to sign and return)
Yes
No
Clear selection
Do you agree to be added to our mailing list so we can send you the necessary Covid Information? (South Derbyshire CVS will not contact you about anything else unless you want us to).
Yes (you may contact me about Covid Information Connectors and other SDCVS news)
Yes (but only contact me about Covid Information Connectors)
No
Clear selection
Comments
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
