Name Have you been advised by the NHS to self-isolate? * Yes, I have been contacted by the NHS No, I have not been contacted This could have been from a doctor or by letter in the post Are you currently showing signs of COVID-19? * Yes No Symptoms include persistent cough, trouble breathing, high temperature First Name * Your first name Second Name * Your second name Email Address Your email address Your Phone Number * Your Address * Please fill in your address so we can arrange deliveries to you Dietary Requirements Please tell us of any dietary requirements you have. Are you in urgent need of food now? Yes I am No I am not Saying 'no' does not mean we won't help. Do you have an income? Yes, I have No, I do not Income Are you in receipt of benefits? No, I am not Yes, I am The next time I will receive a payment of income or benefits will be: Within the next 7 days Within the next 14 days Within the next month I don't know Are you able to get to the shops yourself to buy food? Yes No Are you able to contact someone who will be able to buy food for you? Yes No Do you have elderly people or children dependent on you who also require food? Yes No Do you have a health condition or disability we should know about? Yes No Please add any other information we should know.