Village Agent Support Request

Email
This field is for validation purposes and should be left unchanged.
Your first name*
Your last name*
Your address*
Postcode*
Contact telephone number*
Email address (optional)
Your email address if you would like to be contacted via email.
Date of birth
Month
Day
Year
Gender
Ethnicity
Ethnic groupPlease select
What help do you need?
How can we help?*
Village Agents make home visits to older people living in villages in Bedford Borough, to help them with free support & assistance. Can you say more about the help you need?

Communication
Preferred language
What language do you prefer to communicate in?
Communication needs*
Do you (or the person you are enquiring for) require an Interpreter e.g. sign or language?
- No
- Yes
Further communication information
If yes, please give details of person who is able to provide support to discuss referral (if available):
Disability
Are you disabled?*
Do you (or the person you are enquiring for) have a physical or learning disability that we need to be aware of?
- No
- Yes
Further disability information
If yes please say more.

Data protection
The Village Service is run by Bedfordshire Rural Communities Charity (BRCC)

By completing this form you agree to engage with the Village Agent Service and that we can use your information on your behalf to share with other relevant organisations for the purpose of providing this service. It will be kept on a secure computer system in accordance with the General Data Protection Regulation.

To find out more please read our privacy policy.
Your consent
- I give my consent for BRCC to record my personal information so that I might engage with the Village Agent service
- I authorise BRCC to pass my contact details onto the relevant Village Agents so they might offer me help and support
- I have been made aware of BRCC’s privacy policy and know where I can download a copy

What help do you need?