Food Parcel Request - Open Hands Reigate

About You

Name*

Enter your first name Enter your surname

Street Address - house name or number and street address*

Town / Area*

Post Code*

Mobile Phone Number*

Do you drive?*

Yes
No

Pets?*

Dog
Cat
None

Current Circumstances*

Your Household

No of Adults (18 & over)*

Do you have children?*

Yes
No

No of Children (17 & Under)

Please enter a number from 0 to 8.

First Child's Age & Gender

Second Child's Age & Gender

Third Child's Age & Gender

Fourth Child's Age & Gender

Fifth Child's Age & Gender

Sixth Child's Age & Gender

Seventh Child's Age & Gender

Eighth Child's Age & Gender

Nappies needed?*

Yes
No

Nappy size needed

Baby formula needed?*

Yes
No

What types of baby formula

Preferences

Tea or Coffee? **

Tea
Coffee
None

Are you vegetarian or vegan?*

Vegetarian
Vegan
Pescatarian
No

Are you gluten intolerant?*

Yes
No

Tinned meats?*

Yes
No

Tinned soups?*

Yes
No

UHT milk?*

Yes
No

Toiletries Needed?*

Yes
No

Sugar?*

Yes
No

Jam or marmalade?*

Jam
Marmalade
None

Other

Are you currently receiving help from another food bank?*

Yes
No

Which food banks are helping you?

This will not affect them receiving a parcel from us, but it's helpful for us to know.

Are you a referring agency?*

Yes
No

Referring Agency (if you are referring a client only)

Referrer's Telephone Number

Referrer's point of contact name

I give my permission for Open Hands Reigate foodbank to cross reference my details with other foodbanks, should it become necessary.*

Yes
No

By completing this form, you are agreeing to your details being sent directly to Open Hands Reigate, so that they can complete the registration process. Open Hands Reigate will not use your personal details for any other purpose other than that which you have consented to.