'Helping Hands' assistance request form
Kia ora & Assalamu alaikum,

This form has been set up by the Pearl of the Islands Foundation (PIF), Khadija Leadership Network (KLN), and Who is Hussain? (WIH) to provide basic & essential support for people at risk or self-isolating in need of assistance.

Anyone needing help during this lock-down is requested to fill out this form. A volunteer will then be connected with you according to your needs. If it is easier, we encourage you to use the Helpline to ask for assistance. The Helpline number is 09 282 3175.

At this stage we have a small number of volunteers so please do not be offended if we are unable to assist immediately. Our volunteers will use protective equipment available to them (e.g. masks and gloves) to keep you safe as they assist you. They also undergo a brief training, and we also maintain regular contact with appropriate government agencies to be able to ensure we can assist you during this lockdown period.

Noho ora mai (stay safe),
PIF, KLN, WIH

Privacy waiver:
The information collected via these forms will be used by supporting organisations to provide you with the essential support needed during COVID-19 lockdown in Aotearoa New Zealand. The organisations will also use this information once lock-down is over to seek your feedback on how they can continue to serve you. The information collected will remain with the organisations listed out for you with logos on the form. The representatives of any of these organisations can provide you with the information they hold about you, and can remove you from their mailing lists whenever you request.
Email address *
Your name? *
Your answer
Your contact details? (Email & mobile number) *
Your answer
Which of the below do you need help with? *
Required
Are you? *
Required
When do you need assistance? (asap, specific date, whenever, etc.) *
Your answer
Is there anything else we need to be aware of? *
Your answer
Which city & suburb are you located in? *
Your answer
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