Shacklewell Ward Covid MutualAid Request for Help
This is the form for those looking to RECEIVE support from the Shacklewell Ward Covid MutualAid volunteer group. You can complete it for yourself or on behalf of someone else.
Your data will be temporarily stored in a spreadsheet accessible to organisers of the Shacklewell Ward Mutual Aid group. Your data will be deleted once you have received the support you requested, unless you ask us to store it for longer and contact you again.
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* Required
What name we should call you?
*
Your answer
What phone number can you be reached on?
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Your answer
What is your email address?
Your answer
What is your preferred language? We will do our best to match you with a volunteer who can speak your requested language
*
Your answer
House/Flat Number and Road?
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Your answer
Post Code
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Your answer
Do you agree for a volunteer from the Shacklewell Ward Mutual Aid group to call you on the number you provided to discuss supporting you with your request? If you do not want to be contacted by us we will unfortunately not be able to support you with your request.
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Yes - I am happy for my phone number to be passed on to a volunteer
No - please use my email address instead
No - I do not want you to contact me
Do you have any requirements for being contacted (e.g. certain days/times only)?
Your answer
What support do you need?
*
Food shopping
Collecting prescription
Friendly phone call
Foodbank donation collection
General errands
Other
Required
If you are getting a prescription collected, which pharmacy is it from?
Your answer
If the support you need requires payment (eg. food shopping), what is your preferred method?
*
Cash given to volunteer
Bank transfer to volunteer
Card payment (card will need to be given to volunteer to take with them)
Telephone payment with shop (please check if this is possible with your volunteer)
PayPal to volunteer (please check if this is possible with your volunteer)
Unable to pay (please discuss with volunteer)
No payment required for the help I need
How urgent is the support you need
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I need this support today
I need this support in a couple of days
I need this support within a week
I have a specific deadline for this (please say in the 'Is there anything else you want to tell us?' question)
Other:
Is there anything else you want to tell us?
Your answer
Would you like us to keep your contact and check in with you in a couple of weeks or a month to see how you are?
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Yes - I agree for you to keep my personal information until this time
No
Are you filling out this form for yourself or on behalf of someone else?
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Myself
For someone else and I have their verbal consent
For someone else and I have their consent in writing
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