New Wine Support Required Nomination

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Please provide your current details and the person you are nominating to be supported by New Wine Church. You can nominate up to 10 people using this form. If you have more than 10 nominees, you can use multiples of this form

Email *

Your Title *

Your First Name *

Your Last Name *

Your Mobile Phone Number *

Nominee 1: Name *

Nominee 1: Telephone Number *

Nominee 1: Reason for nomination to get support *

Senior Citizen/Elderly

Not elderly but with health challenges

COVID-19 Front line / Key Worker

Living alone (Staying by themselves during the 'lockdown')

Need for dry food (From John Wilson Food bank)

Other

Please specify, if 'other' was chosen above

Nominee 2: Name

Nominee 2: Telephone Number

Nominee 2: Reason for nomination to get support

Senior Citizen/Elderly

Not elderly but with health challenges

COVID-19 Front line / Key Worker

Living alone (Staying by themselves during the 'lockdown')

Other

Clear selection

Please specify, if 'other' was chosen above

Nominee 3: Name

Nominee 3: Telephone Number

Nominee 3: Reason for nomination to get support

Senior Citizen/Elderly

Not elderly but with health challenges

COVID-19 Front line / Key Worker

Living alone (Staying by themselves during the 'lockdown')

Other

Clear selection

Please specify, if 'other' was chosen above

Nominee 4: Name

Nominee 4: Telephone Number

Nominee 4: Reason for nomination to get support

Senior Citizen/Elderly

Not elderly but with health challenges

COVID-19 Front line / Key Worker

Living alone (Staying by themselves during the 'lockdown')

Other

Clear selection

Please specify, if 'other' was chosen above

Nominee 5: Name

Nominee 5: Telephone Number

Nominee 5: Reason for nomination to get support

Senior Citizen/Elderly

Not elderly but with health challenges

COVID-19 Front line / Key Worker

Living alone (Staying by themselves during the 'lockdown')

Other

Clear selection

Please specify, if 'other' was chosen above

Nominee 6: Name

Nominee 6: Telephone Number

Nominee 6: Reason for nomination to get support

Senior Citizen/Elderly

Not elderly but with health challenges

COVID-19 Front line / Key Worker

Living alone (Staying by themselves during the 'lockdown')

Other

Clear selection

Please specify, if 'other' was chosen above

Nominee 7: Name

Nominee 7: Telephone Number

Nominee 7: Reason for nomination to get support

Senior Citizen/Elderly

Not elderly but with health challenges

COVID-19 Front line / Key Worker

Living alone (Staying by themselves during the 'lockdown')

Other

Clear selection

Please specify, if 'other' was chosen above

Nominee 8: Name

Nominee 8: Telephone Number

Nominee 8: Reason for nomination to get support

Senior Citizen/Elderly

Not elderly but with health challenges

COVID-19 Front line / Key Worker

Living alone (Staying by themselves during the 'lockdown')

Other

Clear selection

Please specify, if 'other' was chosen above

Nominee 9: Name

Nominee 9: Telephone Number

Nominee 9: Reason for nomination to get support

Senior Citizen/Elderly

Not elderly but with health challenges

COVID-19 Front line / Key Worker

Living alone (Staying by themselves during the 'lockdown')

Other

Clear selection

Please specify, if 'other' was chosen above

Nominee 10: Name

Nominee 10: Telephone Number

Nominee 10: Reason for nomination to get support

Senior Citizen/Elderly

Not elderly but with health challenges

COVID-19 Front line / Key Worker

Living alone (Staying by themselves during the 'lockdown')

Other

Clear selection

Please specify, if 'other' was chosen above

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Note: Your Nominations and Answers will be Treated with Strict Confidentiality

A copy of your responses will be emailed to the address you provided.

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