Rawiri Community House Referral Form
If the form is not showing come back during these times. Food parcels are only available for collection ON WEDNESDAYS and THURSDAYS from 10am - 12pm and 1pm - 2pm. If you miss your pick up time your application will be cancelled!!!
PLEASE NOTE!!!
IF YOU LIVE CLOSER TO ANOTHER FOOD ASSISTANCE PROVIDER YOU WILL BE REFERRED TO THEM.
Is this a self referral
*
Yes
No
If NO name of the referral organisation?
*
Personal Details
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Day
-
Month
Year
Date
Gender
*
Female
Male
You must enter your email to receive a food parcel
*
example@example.com
Contact Phone Number
*
-
Area Code
Phone Number
Ethnicity
Maori
Tongan
Samoan
European
Cook Island
Asian
Indian
Middle Eastern
TELL US ABOUT YOUR SITUATION
Marital Status
*
Please Select
Married
De facto
Single
Widow
Number of people in your household
*
Employment Status
*
Please Select
Unemployed
Student
Employed
How can we assist you
Food
Skinny Modem (if email has been used with skinny use a different email)
Driver License Training
Household Items (subject to availability)
Advocacy for MSD
Advocacy for Probation
Advocacy for Kainga Ora
Advocacy for Oranga Tamariki
Reason why you need assistance
*
Extra assistance
Pet food
Sanitary items
Please note pet food will only be distributed if available
Please Select
Dog Food
Please note nappies will only be distributed if available
Please Select
Infant Size 2
Crawler Size 3
Toddler Size 4
Please note sanitary pads will only be distributed if available
Please Select
Regular
Super
Food parcel pick up day
*
Wednesday 10am - 12pm
Wednesday 12.30pm - 2pm
MUST BRING PHOTO ID AND PROOF OF ADDRESS
*
Photo ID
Proof of Address
Do you need help with budgeting
Yes
No
Are you interested in Volunteering
Yes
No
Maybe later
Have you received food assistance from Rawiri Community House in the past
*
Please Select
yes
no
not sure
You will be notified of an available time for pick up
*
Yes
Staff use only (do not tick below)
Accept
Decline
Time
Hour Minutes
Submit
Date
/
Day
/
Month
Year
Date
Should be Empty: