Sign up form

Sign up form
A service for clinically extremely vulnerable (CEV) adults living in Somerset

Our aim is you support anyone who is feeling lonely, isolated and connect you with another person who is on the CEV list to keep your spirits up – you are not alone!
Your details
What are your main hobbies and interests? (please type up to 5 things you are really interested in)
Name *

First Name Last Name
Address

Street Address Line 2

Town

Post Code
Email address
Preferred Telephone Number
Age

18 - 24 years 25 - 29 years 30 - 39 years 40 - 49 years 50 - 59 years 60 - 69 years 70 - 79 years 80+
Are you:

Male Female Prefer not to say Other
Your Preferences
What is your main language?
What is your level of spoken English?

Good Average Basic
If you have a disability does it affect your ability to talk to others by telephone or online?

Yes No Prefer not to say
If Yes, to allow us to help you please tell us more:
Which days of the week and time would suit you?

ANY DAY Monday Tuesday Wednesday Thursday Friday Saturday Sunday ANY TIME Morning Afternoon Evening
Do you prefer to speak to?

Male Female Don't mind
Do you prefer to talk to others using:

Telephone Video calling Don't mind
If you want to use video calling which type of platform do you prefer?

WhatsApp Zoom FaceTime Skype Other
Help with your phone, tablet or computer
Do you need help with digital support to connect?

Yes No
This could be help with using a smartphone, tablet, computer for speaking to others on WhatsApp, FaceTime, Zoom or accessing the internet, help setting up an online food shop, etc.
Our guidelines
All those taking part in the Chat to Connect service should be courteous and respectful to others at all times. Any form of abuse or harassment will not be tolerated and further legal advice may be taken.
Permission
I agree to Smart Communities (part of the CCS group) holding the personal information I have outlined above on their database. The only personal information that will be shared with my Chat to Connect partner is my name and type of contact details. No other information will be shared with any other parties without my consent.

I understand that the Chat to Connect partner will not be DBS checked. I also agree to the guidelines above.
Signature *

Clear
Date *

Month Day Year
Date
If you are not completing this form yourself, please state the name of the person filling out this form on your behalf
Is this person:

A family member A friend CCS Agent Healthcare professional Personal carer Other
Protecting your details

PLEASE NOTE: We will only connect people who appear on the Somerset County Council’s Clinically Extremely Vulnerable (CEV) list which has been shared with the Community Council for Somerset (CCS) for the purposes of providing support to these people during the pandemic. The only information that Smart Communities part of the CCS group will disclose to initial contacts will be your name and preferred type of contact details so that a connection can be made. Please be careful about what personal information you choose to disclose.
Delivered by Smart Communities part of the CCS group & Funded by Somerset Community Foundation
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Sign up form

A service for clinically extremely vulnerable (CEV) adults living in Somerset

Your details

Your Preferences

Help with your phone, tablet or computer

Our guidelines

Permission

Protecting your details