Knighton and District C-Virus Support
Are you looking for some support or social contact during the ongoing Covid 19 Pandemic? If so please complete this form to help us identify someone to provide support for your needs. This response may also be used in the main PAVO systems so please complete as much information as you can
This support request is being made by
Relative not in the same house
If you are requesting help for someone else please add your name address and phone number here then complete the rest of the form as if you were the person requesting support
My name (please write your Facebook name as well if you have one)
My email address
Alternative Phone number
How old are you
Which surgery are you registered with
I am not registered
Are you or anybody in the household
Required to self isolate as a vulnerable person
Isolating due to infection
Under normal lockdown
Shielded as 'extremely vulnerable'
Do you have any of the following local support
Do you need any support
Yes, as soon as possible
Yes, but not urgent
If you require a snack lunch, could you let us know how many lunches you need?
What sort of support do you think you will need
Regular phone call
Telephone befriending scheme
Online social activity
Welfare rights / benefits advice / Food Bank
Stay and Play for parents, carers and young children
Help for young people
Support as a carer
Hot meal / soup delivered to your house
Support from the Clergy / religious group
If you require meals/snack lunch, do you have any food needs?
If yes to online activity, What type of online social activity would interest you?
Group chats with friends
Do you have access to the internet
Mobile phone only
Do you have any other support needs or activity ideas that you would be interested in
During this outbreak, the support group and partner voluntary sector organizations may wish to contact you with newsletters, information and support ideas. Do you give us permission to add your email address to these mailing lists for the duration of this virus outbreak?
Your private information is very important to us. The information on this form will not be shared with anybody without your agreement. If we feel that somebody could help you, we will ask for your agreement for it to be shared. You can ask us to destroy our records at any time. At the end of the C-Virus crisis, all records will be destroyed. The Knighton Community Centre holds the data and can be contacted on 01547 428088. Are you in agreement with your information being held?
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