Community support request form

Communities 1st want to help local people to support one another and provide essential services to people who need it.
The purpose of this form is to collect your contact details so we can help connect you to support from a member of staff or a volunteer in your community. We also ask some other questions to find out more about the kind of help you need.
If you need any help completing this form, please contact Communities 1st on 01727 649900 or email help@communities1st.org.uk

Details of the person requiring support
Next of Kin Details
Are you filling this form out for yourself
Form-filler Information
Information of the individual filling out this form
What do you need help with?
Additional Info
Gender
I am
Are you a Carer?
What is your ethnic background?
Do you regard yourself as having a disability?
Tell Us About Yourself
Do you have any underlying health conditions?
Do you live alone?
Do you have children under the age of 18 in the household?
Do you have any allergies?
Are you receiving support from social services?

By submitting this form, you are agreeing to your details being shared with local community groups, Council services and its health partners, so that we can help support you as part of our service response. The legal basis for this use is your consent. Your information will not be used for any other purpose. You can withdraw this consent at any time by contacting the email address given, and Communities 1st will remove your data and inform other providers to do so. Our full privacy statement giving your rights is online, or ask us for an accessible copy.