Application for Emergency Relief | Lifeline Darling Downs

By completing this form, I acknowledge and agree that:

I am requesting material assistance through provisions provided by Lifeline Darling Downs and South West Queensland Ltd.
I consent to my details being shared with authorised representatives from Lifeline Darling Downs and South West Queensland Ltd.
I understand that these representatives may contact me via phone, email, or other provided contact details for the purpose of coordinating this support.
I understand that my information will be used only for the purpose of arranging this assistance and reporting to funding bodies, and will be handled in accordance with confidentiality and privacy requirements.
All information is collected and securely held by our organisation. If you have any questions about this Privacy Statement, please contact the Privacy Officer.

Date *

First Name *

Last Name *

Date of Birth *

Contact Number *

Please enter a valid phone number.

Contact Email

example@example.com

Is it safe to contact you via the phone? *

Can we safely leave a message for you if you miss our call? *

Is there another way we should contact you?

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Gender *

Country of Birth *

Do you identify as Aboriginal or Torres Strait Islander? *

Do you identify as LGBTQA+ *

Do you identify as Culturally and Linguistically Diverse *

What do you need help with?* *

Food & Essential Living Items

Clothing

Household Goods

Furniture Assistance

Pharmacy Assistance

Other

Comments

The personal details you enter into this form will be collected and stored by our organisation. Please confirm that you understand and agree *

We will always store your personal details securely. We will use them to provide the service you have requested and communicate with you in the ways you have agreed to. Your data may also be used for analysis purposes to help us provide the best service possible.
For full details please see our Privacy Policy - https://www.lifelinedarlingdowns.org.au/privacy-policy

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