COVID-19 – Request Community Support

Please complete this form if you could benefit from support or know someone that would.

I consent to sharing my data with groups and individuals committed to supporting a Slough response to Coronavirus. We will not share your data with anyone that would sue your data for profit.

I Consent

I am filling in this form on behalf of someone else and they have provided me with consent

Please provide at least one means of contact

Name of person requiring support

Phone number of person requiring support

Email of person needing support

Email of person filling in this form if different from above

Address of person requiring support including postcode

Is this person...

Support Required

Fresh food

Non perishable goods e.g. tinned food, cleaning products, toilet roll.

Medicines or prescriptions picking up

Daily welfare call

Unknown (we can call to find out precise needs)

Health welfare checks - regular catch up

OtherOther

Name of person completing form (if different from above)

Telephone number of person completing form (if different from above)