Request help

Complete this Confidential form to get assistance

Please complete the form below to get help for yourself or someone else

Is the help for you?
YesNo

Which best describes your circumstances - select all that apply (required)
IsolatedElderSick or IllDisabledVulnerableHomelessVulnerable with Childrenaffected by COVID19 emergencyLow or no income householdFurloughed full time workerzero hours furloughedsheltered livingLife limiting conditions or Physical Health ProblemsAsylum seeker or refugeeNEETSBME heritageDrug or alcohol addictionCarerMental health problemsDomestic violenceEx offenderEx service personellLGBTQALong term unemployedYoung people or In care or care leaversLone parentUniversal CreditDo not wish to state

Please select what you need help with - select all that applyCooked packed foodFresh VegetablesFresh fruitsUHT milk/Fresh milkBreadCerealTinned foodsRice or PastaFlourToilet rollToiletriesHand soap or hand wash or Bars of soapBaby formula / Baby food **please state age and type in commentsBaby nappies ** please state age and type in comments

We are introducing food boxes to supplement our cooked food and food bank packs. Food boxes contain a few essentials and treats and will be sent to you every week. Food boxes are free. If you would like to subscribe to our food boxes sent on a weekly basis and agree not to resell the items in the box please tick yes. YesNo

Where did you hear about us pleasefriendsocial workerlocal councilreligious leadersocial mediainformation leafletonline searchhelp websitefood aid networkmutual aid website

By completing this form you agree for a coordinator / volunteer for Action Force Community Group to contact you. **We may also call you or send SMS messages to your phone to check your availability. **We may share your information with other reputable groups and agencies and our volunteers so we can deliver you some assistance quickly and effectively. We aim to get help to you within 36 hours *
YesNo