Food & Care Drive Agency Referral Form
We’re collecting information on seniors and caregivers in need of food and care items. This helps us coordinate delivery, prioritize urgent needs, and bridge gaps for those who give and receive care.
Agency Information
Agency Name
Contact Person
First Name
Last Name
Title/Role
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Agency Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Recipient Information
Is this referral for a senior or caregiver
Senior
Caregiver
Recipient Name
First Name
Last Name
Address (for delivery or pickup)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is this recipient an active client or caregiver in your agency?
Yes
No
How did you Identify this person as being in need?
Referral from family
Staff observation
Self-request
Other
If "other" please explain.
blanks
blank
Needs Assessment
What type of assistance is most needed?
Nonperishable food items
Fresh meals
Grocery gift card
Toiletries/personal care items
Household supplies (cleaning, paper goods, etc)
Urgency of need:
Immediate (within 3 days)
Within 1 week
General assistance (anytime during the drive)
Household size:
Adults
Children
Dietary Restrictions
Yes
No
If yes, please list:
Authorization & Consent
By submitting this form, you confirm that the information provided is accurate to the best of your knowledge and that the individual(s) listed have consented to being contacted or supported by The Seasons of Care Foundation.
Photo/Media Consent: I give The Seasons of Care Foundation permission to take and use photos or videos of me (or the person referred) for social media, website, or other outreach related to the Food & Care Drive.
Yes, I give my permission
No, I do not give permission
Signature
Date
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: