Community Needs

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No fields are required. If you include an email we can confirm your submission.

Language

Is English your first language? Preferred language Interpreter needed? Accessibility support needed? (select all that apply)

Deaf / hard of hearing Sign language interpreter Blind / low vision Other accessibility support

Mobility support (select all that apply)

Uses wheelchair Limited mobility Requires home visit Other mobility support

Your details

Full name Address line

Suburb Postcode

Email Phone Preferred contact method I'm completing this form for someone else

Your needs

Needs (select all that apply)

Other details

Urgency Details How badly affected? (1-10) Estimated budget (optional) Household size (number of people)

Household age groups (number of people)

0-5 6-12 13-17 18-64 65+

Consent & sharing

I confirm the information is accurate to the best of my knowledge. You may contact me about additional support options.

We understand that not everyone wants their information shared but is providing it to the community for statistical reasons.

I don't want my information shared with CCC I don't want my information shared at all I don't want any help even though I am impacted Add me to the petition calling for faster community action and faster building of the new sewage treatment plant

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