Blanket and Beanies Request Form

Blanket and Beanie Request Form
Free blankets and beanie hats are available to support vulnerable residents of North Somerset in staying warm during emergency situations.

This initiative is designed for individuals facing challenges in maintaining warmth at home, such as those with a broken boiler, financial constraints affecting heating, or insufficient blankets/bedding to stay warm.
Date*

DayMonthYear
Date
Name of Referrer*

First NameLast Name
Name of organisation
Job role*
Referrers phone number*
Please enter a valid phone number.
What is the request for?

BlanketBeanieBoth
Please provide some reasoning for your referral?
Is the individual in receipt of any support services?*
If so which services does client receive
Client name*

First NameLast Name
Do you require us to deliver Items*

YesNo
Client address*

Street Address

Street Address Line 2

TownCounty

Postcode
Client phone number*
Please enter a valid phone number.
Please provide name of person who will collect items from Access Your Care offices *

First NameLast Name
Please provide Date and time of collection.*
Declaration and Consent

I confirm that the information provided in this referral form is accurate to the best of my knowledge. I also confirm that I have discussed this referral with the individual concerned (or their authorised representative) and obtained their informed consent for this referral to be made. I understand that the information shared will be used solely for the purpose of assessing and addressing the individual's needs and will be handled in accordance with applicable data protection laws and policies.
Should be Empty:

Blanket and Beanie Request Form