Application form for Help or Advice from Isle of Wight Council Safer Community Services
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Application form for Help or Advice from Isle of Wight Council Safer Community Services
Please complete the form giving as much information about the person(s) in need of help or advice as possible. All information provided will remain confidential.
Applicants Details
Title
* Forename
Middle name/Initials
* Surname
* Building/house name/number
* Street address
* Town name
County
* Postcode
* Telephone number
(include area code)
Email address
* Date of birth
Marital status
Not applicable
Single
Married
Divorced
Separated
Widowed
Other
Is this request for help/ advice for you?
If help or advice has been received previously, please tell us what the service was and approximately when the service was last received.
Ethnic Origin
This section is optional but in order to provide a fair and equal service it will help us if you complete it (please click the appropriate box)
What is the person in needs ethnic group White British
Mixed
Asian or Asian British
Black or Black British
Chinese or other

Ethnic Group
Further Details
Reason for Contact

If you have selected 'Other' above, please briefly explain.
If reporting drug related items that are discarded e.g. syringes, needles, please give the following details Location
Type of Drug
related item
Quantity
Date
Declaration

I hereby confirm that the details given in this form are true and correct to the best of my
knowledge.

Signed ...............................................................................

Name.................................................................................

Date...................................................................................
Data Protection Act 1998 
padlock This application may be monitored by the Isle of Wight Council for regulatory, quality control or crime detection purposes. Information from this application will be processed in accordance with the Data Protection Act 1998 for the purpose of processing your particular enquiry/request. The Isle of Wight Council ("the Council") is the data controller. By completing this form you consent to the Council contacting you by email or nominated contact method in relation to your enquiry/request.

The information contained in this application may, in exceptional circumstances, be subject to disclosure to third parties under either the Data Protection Act 1998 or the Freedom of Information Act 2000 to the extent the law allows and in accordance with the Isle of Wight Council's Access to Information Policy . Disclosure will only be made where in all the circumstances it would be fair to do so and in the public interest.

Please note that the Council may process your information in the absence of consent for the purpose of crime prevention or detection so far as is in accordance with the law.

Sometimes we may use your information to keep you informed about services, goods or relevant issues that we believe may be of interest to you. If you wish to receive this information for these purposes please tick this box
To improve the quality of other services that we provide to you the Council wishes to hold your non-sensitive personal information on a secure central database. This will enable all Council services to use this information when they are providing a service to/for you. If you wish your non-sensitive personal information to be held by the Council please tick this box

Date printed: 07/03/2013