Food Pantry Application
Applicant Details
Name
First Name
Middle Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Address
NI number
Email
example@example.com
Tel number
*
Please enter a valid phone number.
Format: 00000-000000.
Postcode
Allergies / dietary requirements
Household Members 1–4
Partner, Child etc
Household Member 1
Relationship to Client
Full Name
First Name
Middle Name
Last Name
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Age
Other Info (allergies, dietary requirements, etc.)
Household Member 2
Relationship to Client
Full Name
First Name
Middle Name
Last Name
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Child Age
Other Info (allergies, dietary requirements, etc.)
Household Member 3
Relationship to Client
Full Name
First Name
Middle Name
Last Name
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Child Age
Other Info (allergies, dietary requirements, etc.)
Household Member 4
Relationship to Client
Full Name
First Name
Middle Name
Last Name
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Child Age
Other Info (allergies, dietary requirements, etc.)
Income and Benefits
Total household income – Amount
*
Total household income – Per
*
Please Select
Week
Month
Year
Other
Household Expenses
Mortgage / Rent payable – Amount
*
Mortgage / Rent payable – Per
*
Please Select
Week
Month
Year
Other
Council Tax payable – Amount
*
Council Tax payable – Per
*
Please Select
Week
Month
Year
Other
Gas, Electric and Water payable – Amount
*
Gas, Electric and Water payable – Per
*
Please Select
Week
Month
Year
Other
Average food cost per person per month – Amount
*
Childcare costs – Amount
*
Childcare costs – Per
Please Select
Week
Month
Year
Other
Pantry Selection and Referral Reasons
Preferred Pantry
*
West Lancs Villages (Tarleton)
High Park (BDS)
Birkdale
Formby
Southport (Grace)
Reasons for Referral
*
Additional short-term support
Budgeting
Debt
Further details about reasons for referral:
If you have ticked 'short term support' or there is any other information relating to the reason for the referral please provide us with more detail in the box below (i.e. medical conditions, financial difficulties, debt, benefit deductions etc.
Complete details here
Commitments and Consents
As part of your 12-month Pantry membership, we ask that you actively engage with the services and support we offer. This helps us make sure we can best support you with the reasons for your initial referral. One of the services we offer is our Budgeting and Taking Control of Your Money workshop. You will need to attend this workshop within the first 6 months of your Pantry membership in order to continue your membership for the remainder of the 12-month period. By signing this referral, you are confirming that you agree to engage with the support we offer and attend any relevant courses, workshops and/or groups, including the required budgeting workshop. We’re here to support you throughout your Pantry membership and encourage you to make the most of the services available to you.
Do you agree to these commitments?
*
Please Select
Yes
No
Do you consent to your information being held by Compassion Acts?
*
Please Select
Yes
No
Privacy Statement – Your personal information is used to assess eligibility and provision of the Food Pantry as well as for monitoring and statistical analysis. Your personal information is only seen by people who need to do so within Compassion Acts. It not used for any other purpose. Information from your referral is accessible to Compassion Acts and the Food Pantry where you attend. Your personal information is stored in a secure database owned and administered by Compassion Acts for data, statistical and monitoring purposes. Your data is kept for six years. Your personal data will never be sold to any other bodies. To find out more about how we look after your personal information please emailoffice@compassionacts.uk
Contact Consent – Phone - In order to discuss your food pantry application and manage your attendance, we will need to call you
*
Please Select
Yes
Contact Consent – Email
*
Please Select
Yes
No
Contact Consent – By Post
*
Please Select
Yes
No
Please note: You are entitled to refuse permission for data to be kept or for us to contact you, however this will prevent us from being able to provide access to our services
By submitting this form, you are confirming and agreeing with the following:
The information on this referral is correct to the best of my knowledge. I agree that I will continue to engage with Compassion Acts, including attending any identified courses and/or groups:
Date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Submit
Clear All Questions
Should be Empty: