Impact of Covid-19 Restrictions

Name*
First Last
Address*
Street Address City/Suburb/Town State Postcode
Email*
Mobile (optional)
Business name (if applicable)
How will ongoing restrictions in regional Victoria affect your life, health, community, or business?*
Would you be happy for your story to be spoken about publicly, in Parliament, and/or in media?*
- Yes
- No
Can I use your name when speaking about your circumstances?*
- Yes
- No
Phone
This field is for validation purposes and should be left unchanged.