Emergency Food & Grocery Pack Referral Form

HILS “Emergency Supply Pack” Referral Form

Important information:
- Deliveries will normally be made between 11.30am and 2pm throughout Hertfordshire seven days a week, 365 days a year. Please provide delivery details for places/people that can receive the Emergency Supply Pack within this time frame.
- For same day delivery for a standard pack with long-life products, HILS must receive referrals by 10:30am
Provision of personal data: we cannot provide a service without a minimum amount of personal information. These sections of the form are mandatory on this form. Please ensure that you have the client’s permission to share their data, if you are completing the form on their behalf. Please see our full privacy statement on our website link below, or give us a call on the number above.

www.hils-uk.org/privacy-policy

Before you start

You can save the form at any time and return to it later by clicking the save button at the end of each page. If you do not want to create an account, you can skip this and either copy the link to your form, or provide an email address to receive a link to your draft form.

If you have any issues completing this form, please email: hertsmeals@hils-uk.org

Eligibility
YesNo
Client's details (person receiving the pack)

This information is necessary for us to ensure the right person receives the pack.
Name*

First NameLast Name
Address Line 1*
Address Line 2
Town*
County*
Postcode *
Telephone (main)*
Telephone (other)
Ethnicity
We are required for monitoring purposes to ask the ethnicity of all our clients to ensure the equality of our service. Please select the client’s ethnicity from the list above
YesNo
The client has been made aware of this referral

Delivery and Access Details
Address for delivery

Address Line 1

Address Line 2

CityCounty

Post Code
Telephone (associated with the above address)
Is there anything we need to know about delivery? e.g. is the house difficult to find?
Please detail any safeguarding concerns you may have regarding the person or their family which our staff may need to know before going into their home:

Eligibility