EMERGENCY FOOD PARCEL
SUPPORTING FAMILIES THRIVING SOCIETY
STAY CALM, BE KIND AND BE SAFE
Pick up from : 176A Lincoln Road Henderson 0610-Auckland ( Every THURSDAY at 12pm). We collect and rescue good fit food to support families those in need and it may run out quickly , Before filling up this form please make sure you turn up on time or as early as possible to avoid disappointment. You don't have to wait for confirmation. Please come and pick up . Only Thursday at 12 pm ( First Come First Serve) Nga Mihi Nui
How did you hear about us / who reffered you to us?
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Ministry of Social Development
Social Worker / Social Services
Family / Friend / Word of Mouth
Kainga Ora
Health Organization like Hospital
Your Community Organization
Online / Social Media / Website/ facebook
Do you want to proceed and submit a request for FOOD PARCEL .
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Yes
No
Have you received Food Parcel from HOPE in the past?
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Yes
No
Have you been impacted by recent weather /flood/ cyclone and this have caused significant damage in your household?
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Yes
No
How many weeks do you need support . Please note you may be asked to share the progress/ updates or actions you have taken to meet your needs.
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Only once
Two weeks
Three weeks
Four weeks
Five Weeks
Six Weeks
Your Legal Name
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First Name
Last Name
Gender
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Male
Female
Other
Your Immigration Status
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Citizen
Permanent Resident Visa
Work Visa
Student
Visitor
Asylum Seeker
Partnership Visa
Your Ethnicity
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For example, Maori, Tongan, Samoan, Pakistani, Indian ,Chinese, Fijian, Burmese, NZ European, Sri Lankan , African,
Total Number of family members.
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Including Children and adults
Total Number of Children living in household/
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Children under the age of 12
Your current employment situation?
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Full-time
Part time
Casual Contract/ Not guaranteed work
Job seeker
Student
ACC Payments
My partner works but we still need more support
Sickness benefit
Super Gold /Pension
Supported Living
Not working/Seeking job
Other
Contact Information
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone No:
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Please write your valid phone number
Email Address :
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example@example.com
Please confirm if you can pick up your Food Parcel. Every time our Food Package is different and it may only helps you to go through difficult times.
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I/We can pick up FOOD PARCEL and I/we understand to show up as early as possible to avoid disappointment.
By filling this form ,you understand and confirm that above information is true and correct to the best of your knowledge. We may ask you to provide your ID, False or misleading information may delay your request. We only hold your information for the purpose of FOOD PROGRAM. We will not share your information with third party without your consent , We may share your information with Ministry of Social Development, Police or New Zealand Government if required by the Law. By signing this form you agree and understood above statement.
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Agree
Signature
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