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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What name we should call you? *
What phone number can you be reached on? *
What is your email address?
What is your preferred language? We will do our best to match you with a volunteer who can speak your requested language *
House/Flat Number and Road? *
Post Code *
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. *
Do you have any requirements for being contacted (e.g. certain days/times only)?
What support do you need? *
If you are getting a prescription collected, which pharmacy is it from?
If the support you need requires payment (eg. food shopping), what is your preferred method? *
How urgent is the support you need *
Is there anything else you want to tell us?
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? *
Are you filling out this form for yourself or on behalf of someone else? *
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