H/DYCA COMMUNITY FOOD BANK COVID-19 FORM

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Hello ,Thank you for your interest in the food bank, due high demand in order to be eligible for this food bank can you please fill in this form, we will aim to contact you within 24 hours of this request.

Name *

Address *

Postcode *

Date of Birth *

YYYY

Phone number *

We will aim to contact you within 24 hours to arrange collection of your emergency food parcel, Monday - Thursday.

Email *

Are you employed *

Deliveries

We may be able to deliver if you live in B63 do you require a delivery? *

Reason for delivery Please be advised deliveries are subject to availability of volunteer delivery drivers. *

Over 65 years

Physical disability

Single parent (self-isolating)

Other:

What day would you prefer to collect your food parcel? *

Please note our emergency food bank collection days are Mondays and Wednesdays by appointment only.

Terms & Conditions *

Please tick the boxes below to confirm you have understood our terms and conditions and print your name.

Yes I confirm

Required

Food Supply *

You understand that ALL of the food supplied has been donated to the Food Bank by the public and sponsors and is accepted in good faith.

Yes I understand

Required

Information Sharing *

I confirm that I give my consent or have permission to share the information provided on the referral form, for the purposes of accessing the food bank.

Yes I confirm

Required

Stay Connected

I would like to be informed of H/DYCA news, fundraising effort and volunteering opportunities.

Yes

Submit

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