Mangere COVID-19 Support Request Form
This form is to record the details of anyone in Mangere who is seeking support from one of our volunteers who helps those in our community who may be vulnerable due to the COVID-19 pandemic and Alert Level 4 lockdown.

Some people will need assistance with simple tasks like collecting groceries or medications as it is not safe for them to leave their homes during this lockdown.

We appreciate you reaching out to us.
Your Mangere Connect Team

Email address *
What is your full name? *
What is your address? *
What is your phone/mobile number? *
What is your date of birth? *
Please select your situation: *
Were you employed & working prior to COVID-19? *
How has your family been affected by the lockdown? *
What are your biggest needs right now? *
Do you have any high-risk family members in you house? *
If YES, tell us their condition or disability and how lockdown is impacting them and you. *
How many family members live in your house? *
How many are 1-5 years old? *
How many are 6-9 years old? *
How many are 30-69 years old? *
Do you consent to being contacted by one of our team members? Please type YES into the text field below. *
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