COVID-19 EMERGENCY AID

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Personal details
First Name*
Last Name*
DOB*
Address*
Street Address City County Post code Country
Phone*
Email*
Health issues
Medical issue*
Medical necessity information*
Kind of help required during this lockdown*
- Medication
- Counselling
- Food and drinks
- Other
Other [please explain]
Data Protection & Confidentiality
The personal data provided in this form will be processed for the legitimate support reasons in managing your correspondence. We will never sell your data and we promise to keep your information safe and secure. For further details on how your data is used and stored, please see our Privacy and Data Protection Policy.

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