The Village Community Services Trust

COMMUNITY

Food Bank Registration Form
PICK UP ONLY FROM AVONDALE

REMINDER -Bring ID and proof of address. Please remember your time & date, be here 5mins before your appointment, there will only be an email reminder. If by any reason you cant make your appt please reapply for the next available slot. One parcel per household per month.
Name (name on ID)*

First NameLast Name
Phone Number*
Gender*

MaleFemale
Date of birth*

DayMonthYear
Date
other
Ethnicity *
Select one
Email - please make sure its a valid email as this will be your main form of contact*
example@example.com
Identification *
Select an ID type
ID number *
Reason you need support?*

Job lossUnable to meet basic needsSingle parent on single incomeEmergency HousingSomeone in the family is sickAffected by Auckland Flooding
we are here to provide food support to anyone in need, if you are needing ongoing support please provide more information on your situation. we reserve the right to decline applications to repeat requests without further information.

if you have received multiple food parcels from us, please give a brief description of your current situation.
further information if you have recieved multiple food parcels from us. *
Will you be needing support from another organisation, ie: budgeting etc..? *
Pick the time for your food parcel pick up. *pls do not be late.*
Address*

Street Address

Street Address Line 2

City

Postal / Zip Code
Are you registered with Whanau Ora? If yes, provide details. *
Family Size? *
ho w many people in your household
Nappies*

size 5size 4size 3size 2No, Thank you
What is the age of each family member 2?
Member 3?
Member 4?
Member 5?
Member 6?
Member 7?
Birthdate #3

MonthDayYear
Date
Birthdate #4

MonthDayYear
Date
Birthdate #5

MonthDayYear
Date
Birthdate #6

MonthDayYear
Date
Birthdate #7

MonthDayYear
Date
Birthdate #8

MonthDayYear
Date
Birthdate #9

MonthDayYear
Date
Are there any family members with disabilities or with chronic or long term illness? If yes, provide details. *
Please specify
Have you had a parcel from us SINCE 1 January 2022? *
Have you had a parcel from us anytime before? If yes, how many? *
How did you hear about us? *
I understand by clicking submit that any personal information regarding any member of my family will remain confidential, private and secure.
Please Text your full name to 021 845 535 when you arrive at the car park, you will receive a text back, but if you don't have credits then please come up to the door and wait for a staff member. Do not enter the building, due to Covid restrictions you must wear a face mask.

MUST bring ID & Proof of address

BE ON TIME!

We will prioritize first-timers.
Should be Empty:

COMMUNITY

PICK UP ONLY FROM AVONDALE