COVID-19 Dudley Borough Group/Org Registration Form

Logged ID

First Name          

Last Name          

Group/Org name          

Your Locality We are collecting this so we can see where groups are based so we can coordinate activities in specific areas – please tick as appropriate

Halesowen and Quarry Bank

Stourbridge, Lye and Wollescote

Dudley and Netherton

Kingswinford and Amblecote

Brierley Hill 

Sedgley, Coseley and Gornal

Contact Number          

Email Address          

Support What support is your group/organisation able to offer? Check in via phone with people who may need itHelp a vulnerable person with practicalities (e.g. food deliveries, online shopping etc)

Other please specify

         

Would you like to be part of a COVID-19 support network in your area?

Yes  No 

Consent I agree that personal data relating to me which has been obtained by Dudley CVS, including the personal data given by me on this form, may be held and processed either on computer or in manual records and may be disclosed to officers and authorised employees of Dudley CVS and used by Dudley CVS for any purpose relating to my work

Yes  No 

I consent to be added to Dudley CVS’s mailing list to keep up to date about events and projects.

Yes  No 

Please complete and return this form to: admin@dudleycvs.org.ukIf you have any queries please contact: 01384 573381