Coronavirus - request for help form - Runnymede Borough Council

Your details
1. Title*
2. First name*
3. Surname*
4. Address*
5. Town*
6. Postcode*
7. E-mail
8. Telephone*
I need help with
1. Food urgently
2. Essential non-food items (eg nappies)
3. Prescription collection
4. Financial advice
5. Benefits advice
6. Pet walking
7. I’m isolated and need a friendly phone call
8. Have an urgent hospital appointment and need transport
9. Just become homeless
10. I have run out of medication or will do so in the next 24 hours
11. I will run out of medication within two days
2. No-one in my household has coronavirus
3. Someone else in my household has coronavirus or is self isolating
4. I have coronavirus or am self isolating and am the only person in my household
1. I can come to the front door
2. I am not able to come to the front door
4. If you need food and have dietary requirements such as, baby formula, halal, kosher, gluten free food, please explain here. You can also use this space to tell us anything else we might need to know, or ask for another kind of help.
5. Runnymede Borough Council will do its best to help you with the services we run. You may be contacted by one of our staff or a volunteer organisation to meet your needs.
6. Where support can be better provided by another organisation like Surrey County Council, the NHS or police, we will pass on your details to them to contact you directly.
7. Please tick this box to confirm you agree to the Council sharing your details with partners to help you.
* This is a required field, must type in information.