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 *
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
Your answer
My name (please write your Facebook name as well if you have one) *
Your answer
My email address
Your answer
Address *
Your answer
Phone number
Your answer
Alternative Phone number
Your answer
How old are you
Your answer
Which surgery are you registered with
Are you or anybody in the household
Do you have any of the following local support
Do you need any support
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
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?
Do you have access to the internet
Do you have any other support needs or activity ideas that you would be interested in
Your answer
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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