WFRC is a charity-based service, and the Baby Bank depends on donations from the community and well-wishers. This means the items available may change from time to time and cannot always be guaranteed. However, we will always do our best to support families with kindness, dignity and fairness. If any requested items are unavailable, they may be added to a waiting list and families will be contacted once they are donated.
REFERRER'S INFORMATION
Referred by
*
First Name
Last Name
Name of Organisation
Referrer's Email
example@example.com
Phone Number
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CLIENT'S INFORMATION
Client's Name
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Address
*
Street Address
City
State / Province
Postal / Zip Code
Tenure
*
Please Select
Home Owner
Private tenant
Social housing / Housing Association
Homeless / Temporary accommodation
Supported accommodation
Ethnicity
*
Please Select
White – British
White – Irish
White – Gypsy or Irish Traveller
White – Other White background
Mixed – White and Black Caribbean
Mixed – White and Black African
Mixed – White and Asian
Mixed – Other Mixed background
Asian or Asian British – Indian
Asian or Asian British – Pakistani
Asian or Asian British – Bangladeshi
Asian or Asian British – Chinese
Asian or Asian British – Other Asian background
Black or Black British – African
Black or Black British – Caribbean
Black or Black British – Other Black background
Arab
Does the client have any Accessibility issues
Please Select
Unable to collect items in person
Hospitalised/ Pregnancy complications
Language barriers
No phone access / Unable to communicate by phone
Other (please specify)
Employment status
*
Please Select
Employed full-time
Employed part-time
Unemployed
Self-employed
Do they recieve benefits
*
Yes
No
Number of Adults in Household
*
Please Select
1
2
3
4
5
6
7
8
Number of children in Household
*
Please Select
0
1
2
3
4
5
6
7
8
Is this your first referral?
Yes
No
when did you last receive items from WBB?
Are You Pregnant?
*
Yes
No
What is your Due Date?
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Please provide a summary of your situation & specify reasons for requiring support
*
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Details of Child Requiring Items
*
Rows
Name
D.O.B / Due Date
Gender
Disibility
Child 1
Male
Female
Unknown / Prefer not to say
Child 2
Male
Female
Unknown / Prefer not to say
Child 3
Male
Female
Unknown / Prefer not to say
Baby Care & Essentials
Rows
All/ Specific items
All items
Milk
Wipes
Nappies
Toiletries
Toiletries & Hospital Essentials
Rows
All/ Specific items
All items
Sanitary / Maternity Pads
Body lotion
Shower gel
Tooth brush & Tooth paste
Baby Nursery & Equipment
Rows
All/ Specific items
All items
Blankets / Bedding
Pram / Stroller
Bath Tub
Toys / Playmat
Other
Baby Clothing & Accessories
Rows
All/ Specific items
All items
Baby Grows/ Outfits/ Clothing Items
Coats/ Cardigan/ Warm items
Shoes/Socks/Clothing Accessories
Sleeping bags
Is this an emergency referral
Yes
No
How did you hear about us
Please Select
Midwife
Health Visitor
GP / Doctor
Hospital Staff
Social Worker
Family Support Worker
Children’s Centre
School / Nursery
Housing Officer
Charity / Community Organisation
Food Bank
Friend or Family
Word of Mouth
Social Media
Facebook
Instagram
Website / Google Search
Leaflet / Poster
Community Event
Local Council
Self Referral
Other (please specify)
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