Loving and serving the community in Jesus' name

Foodbank Client Referral

Client Consent

To be read to client: St Thomas Foodbank is covered by the Data Protection act. By submitting this request for support you consent to your information being stored on our electronic recording system. Client Agreement (without this you cannot continue) (Yes / No)

Client Name

First Name

Last Name

Client Phone

Client Address

Number of adults and children in the house

Only include those in need of food, please specify separately the adults and children.

Allergies

Does anyone on this application have allergies? Yes / No If yes, please provide details:

Reason for Referral

Why are you referring this client? eg: Application for UC / Delayed benefits / Debt / Hardship / Illness / Other (please state)

Referring Agency Name

On behalf of which organisation are you placing this referral?

Referrer Name

First Name

Last Name

Referrer Email

Referrer Phone Number

(This will only be used by us if we have a query about the referral)

Additional Information

Anything else we need to know? eg. Will this client need supporting for more than one week?

Referrer Information Agreement

I agree to my referrer information being held (yes / no)