Entries marked with * are mandatory.
Please indicate on behalf of the person or household requiring help which of the following are applicable:
- chronic (long-term) respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD), emphysema or bronchitis
- chronic heart disease, such as heart failure
- chronic kidney disease
- chronic liver disease, such as hepatitis
- chronic neurological conditions, such as Parkinson’s disease, motor neurone disease, multiple sclerosis (MS), a learning disability or cerebral palsy
- problems with your spleen – for example, sickle cell disease or if you have had your spleen removed
- a weakened immune system as the result of conditions such as HIV and AIDS, or medicines such as steroid tablets or chemotherapy
- a body mass index (BMI) of 40 or above
We will use the information to provide and coordinate humanitarian support in response to the COVID-19 pandemic. The basis under which the Council uses personal data for this purpose is that is necessary for the performance of a task carried out in the public interest.
The Data Controller is Gedling Borough Council, Civic Centre, Arnot Hill Park, Arnold, Nottingham, NG5 6LU. You can contact the data protection officer at the above address or by email at email@example.com
Further information including how long we retain your data, who we share with and your rights can be found in our privacy notice