Foodbank - NCM

Referral*

Who is filling this form in?

What do you require?

Food Parcel

Hot Meal

Completing referral form

If you are completing this form on behalf of someone, what is your name?

Name of organisation

If you are an organisation completing this form on behalf of someone, what is your organisation's name?

Email address of referrer

If you are completing this form on behalf of someone else, what is your email? We will let you know when an emergency parcel has been sent.

Full Name of Recipient

Address of Recipient

Address line 1

Address line 2

City/Town*

Postcode*

Date of birth*

*

Phone Number of Recipient*

We will aim to contact you within 24 hours to arrange your emergency food parcel.

Email

Are you employed?*

Yes

No

Are you a single parent?

No

Single Mother

Single Father

Have you accessed NCM Foodbank before?*

Yes

No

How many children, if any, are living with you?

How many people are in your household?

What is your reason for accessing NCM Foodbank?

How did you hear of NCM Foodbank?

Do you have a disability or any other issue that our delivery driver should be aware of?

Food supply*

You understand that this form is your self-referral/referral to NCM Foodbank and understand that ALL of the food supplied has been donated to NCM Foodbank by the public and accepted in good faith.

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 NCM Foodbank's services.

Storing your information*

I understands that the information collected on this referral form will be stored by Nelson Community Masjid in accordance with the our policies and may be used for impact evaluation, marketing and funders reports.

Captcha

Foodbank Referral Form

Please use this form to make a referral for an emergency food parcel:

Note: Due to limited resources we are currently only taking referrals for residents of Pendle.

Referral Form

CONTACT US

Bradshaw Street, Nelson, BB9 0BH

01282 899185

07761707613

admin@myncm.co.uk

WE NEED YOUR SUPPORT