COMMUNITY CUPBOARD SELF-REFERRAL FORM

Community Cupboard Self-Referral Form

Request an emergency food parcel if you are experiencing financial hardship due to low income or reduced hours. This form is for working families, individuals in work, and pensioners who live in Newcastle-under-Lyme.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Postcode
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Household Composition (number of adults, number of children, ages of children)
Reason for Referral / Financial Difficulties
Are you currently in work?
If yes, please specify job type and usual weekly hours
Are you currently receiving any benefits?
If yes, which benefits do you receive?
What is your current household income range (per month)?
Have you experienced a recent change in circumstances? (e.g. reduced hours, job loss, unexpected bills)
Do you have any dependants or caring responsibilities?
Please list any dietary needs or allergies in your household
Are you in need of nappies, if so please write down the sizes below.
Do you need period care products? (provided to us by Period Power)
Do you consent to be contacted by Community Cupboard regarding your referral?
Should be Empty:

Community Cupboard Self-Referral Form