Foodbank Form

LBSU Advice Service Foodbank Referral Form
Please read before completing this form:
- Foodbanks are designed to provide short-term, emergency support with food during a crisis.
- They aim to relieve that immediate pressure by providing food.
- Foodbanks provide a minimum of three days’ emergency food to people in crisis.
- Each person is limited to 3 Foodbank Vouchers over a 6-month period.
- Most Foodbanks are only open 1 day a week.
- You can choose to collect your supplies from either the nearest Foodbank to you or an alternative one.
- Check here https://www.trusselltrust.org/get-help/find-a-foodbank/ to find out the opening times of the different Foodbanks so you can indicate which one you would like to collect from further down on this form.
Your Data:
- We need the data on this form to be able to log your details on the Trussell Trust Foodbank Data Collection System which will then issue us a voucher to give to you.
- It will also allow us to set up a case file where we will keep a log of all our interactions with you.
- It will also enable us to offer relevant advice/signposting support.
- We do produce anonymised statistical reports, and we will use the information you provide in those reports but not the details of your case or anything that would identify you.
- We may contact you to ask for feedback.
Once this form has been submitted you can expect to receive your foodbank voucher within 24hrs of us receiving it (except during Weekends, Bank Holidays or when the service is closed e.g. Christmas closure period / staff training days).
Please confirm you understand the above limitations of the support available:*

I confirm that I understand the above information.
Please tell us how you found out that LBSU Advice Service is able to refer you to a Trussell Trust Foodbank:*
Name:*

First NameLast Name
Date of Birth:*

DayMonthYear
Date
Full Address including postcode:*
Student ID Number (8 digits excluding the c)*
Gender identity:*
Ethnicity:*
Other - Please State:*
Mobile Number (11 digits not including international dialling codes):*
University Email:*
yourname@student.leedsbeckett.ac.uk
Personal Email:
example@example.com
Course name:*
School:*

Leeds School of ArtLeeds Business SchoolLeeds Law SchoolSchool of EducationSchool of HealthSchool of Built Environment, Engineering and ComputingSchool of Humanities & Social SciencesCarnegie School of Sport
Mode of Study:*
Academic Status:*
Fee Status:*
If you have a disability you would like to make us aware of please state it here (please also let us know here if you need a reply back in a certain font/size/colour etc and we will do our best to accommodate this in our reply to you):
How did you hear of our service? *
Reasons for need for a Foodbank Voucher (Select all that apply):*

Cost of dependants has increased (for example, if cost increased due to summer holidays)Non priority debtsinclude credit cards, unsecured loans, loans from family & friendsOther unexpected expenditurePriority debts (priority debts will cause serious problems if you do not do something about them soon such as rent or mortgage, gas or electricity bills or court finesChange in work hoursDelay in or awaiting other incomeUnemployment following temporary workChange in dependantsChange in relationship statusDomestic abuseInsecurely housed;Loss of support from family and friendsNo access to financial support due to immigration status
Please give a full explanation of why you are requesting a Foodbank Voucher? This will help us explore if there is any other support that might be beneficial to you.*
Source of income in the household:*

Earning and benefits (includes child benefit)Earning and no benefits (includes pension)Income but no or insufficient access to it (for example,access to a bank account or late student loan)No income
If you are eligible for a Student Loan have you taken one out?*
Please give details:*
If eligible for a free overdraft have you accessed this?*
Please give details:*
Would you like to be emailed a voucher for the food bank located nearest to your address? If you have found that there is a location closer to where you can easily get to, then select No and you can input the postcode of your preferred pick up location.*
If no, what is the postcode of your preferred pick-up location? You can find a Foodbank closest to your preferred pick-up point on The Trussell Trust website linked at the top of this form.*
Please state what action you are taking to ensure you are able to support yourself financially going forward:*
Do you have any dependants you are also requesting food supplies for?*
If yes, give detail of ages of each of your dependants:*
Is there any Additional information the foodbank should be aware of (dietary requirements, including information linked to your health or beliefs for the purpose of providing a nutritionally appropriate food parcel)?Leave blank if you have none.*
I agree to the food bank holding information about my dietary requirements, including information linked to my health or beliefs for the purpose of providing a nutritionally appropriate food parcel.*If a person does not provide consent to sharing their dietary requirements the food bank will only be able to provide a standard food parcel that may not meet their dietary requirements. The voucher issuing process will not be able to proceed if there is information in the dietary requirements box, but consent isn’t confirmed.*

tick box if agree
The food bank may need to contact you to discuss your needs. Please tick Yes if you are happy for us to share your phone number and email address with them:*
Trussell Trust Fair Processing Notice

"We use your personal information to help understand your needs and provide you with emergency food. The food bank and the Trussell Trust are data controllers and have a legitimate interest to use information about you for statistical and research purposes, to show how food banks are being used and why they are needed.

Access to your information is restricted and can only be seen by the agencies who refer you, and authorised people in the Trussell Trust food bank network who need to do so for food bank reasons.

Where you are asked for special category (sensitive) information, we will explain why, and you can choose not to answer if you prefer without this affecting the support you receive. You can withdraw your permission at any time and we will stop using your personal information.

Your personal information is stored in the UK and kept for six years from the date you last received a food parcel.

You have the right to receive a copy of the information we hold about you, and the right to request that we correct anything you believe to be inaccurate and to request we delete your information if we have no need to keep it.

To find out more about your rights or about how we keep your information safe, visit https://trusselltrust.org/privacy or please ask the food bank to give you a copy of their privacy statement."
Please Tick to confirm you have read and understand the above information.

I understand (please tick)
Please double check the information you have provided on this form before submitting so we can be sure we receive your correct information.
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LBSU Advice Service Foodbank Referral Form