Questions marked with an asterisk (*) are mandatory.

1. AGENCY & REFERRER DETAILS

(i) Referrer's name (*)

(ii) Referrer's organisation (*)
Beechwood Primary SchoolBritish Red CrossCaddington SurgeryCentral Beds Council ALDTCitizens AdviceDisability Resource Centre DunstableCSS: Community UnitCSS: Health Visiting ServicesChantry Primary AcademyCrawley Green Infant SchoolDallow Primary SchoolDiscover IslamEarly Help Team Children's ServicesEarly Intervention in PsychosisEast London Foundation TrustFarley Junior SchoolFlying Start WestFlying Start CentralFlying Start NorthFlying Start SouthFlying StartGill Blowers NurseryHart Hill Nursery SchoolIcknield Primary SchoolKeystage Housing (also HARP)Langley House TrustLeagrave Primary SchoolLinden AcademyLuton All Women's CentreLuton Council Children's ServicesLuton Council Stronger FamiliesLuton FoodbankLuton Irish ForumLuton RightsMary Seacole Housing AssociationMeads Primary SchoolMears Housing ManagementNational Probation Service / BeNCH CRCNOAH EnterprisePenrose SynergyPirton Hill Primary SchoolPolish British Integration CentrePutteridge Primary SchoolRamridge Primary SchoolRiverbank Primary SchoolRothesay NurserySacred Heart Primary SchoolSalvation ArmySouthfield Primary SchoolSquaredSt Matthew's Primary SchoolStepping StonesTennyson Road SchoolTerrence Higgins TrustTotal Wellbeing (Active Luton and Social Prescription)Virgin Care - Luton Intermediate Care Rehabilitation ServiceWaulud Primary SchoolWhipperley Infant AcademyWhitefield Primary SchoolWomen's Aid in LutonYMCA BedfordshireWenlock CoE Junior schoolOther

(iii) Referrer's phone number NO SPACES (*)

(iv) Referrer's email (*)

2. CLIENT DETAILS

(i) Client's FIRST name (*)

(ii) Client's SURNAME (*)

(iii) Client's date of birth (*)

(iv) Client's phone number NO SPACES

(v) Client's gender (*)
Prefer not to sayMaleFemale

(vi) Client's address (*)

(vii) Client's postcode (*) NO SPACES

(viii) Is the client participating in any education/courses? (*)
Prefer not to sayYesNo

3. PARCEL TYPES & NUMBERS

(i) Number of adults in household (*)
0 (zero)1 (one)2 (two)3 (three)4 (four)5 (five)6 (six)7 (seven)8 (eight)9 (nine)

(ii) Number of children in household (*)
0 (zero)1 (one)2 (two)3 (three)4 (four)5 (five)6 (six)7 (seven)8 (eight)9 (nine)

Kettle packs are available for people who have no cooking facilities.
(iii) What type of parcels are required?
StandardKettle

(iv) Special dietary requirements (*)
NoneVegetarianVeganHalalGluten freeOther

(iv/a)Details of Other

(v)Number of days' food required

4. NATURE OF NEED Tick all that apply (*)

(i)Waiting for benefit to startBenefits changedBenefits sanctionedBenefits stoppedUnemployedDebtSicknessChild holiday mealsAsylum / ImmigrationStreet homelessSofa surfingFamily crisisCrisis Support refusedOther

(i/a) Details of Other (*)

Universal Credit is a means-tested benefit for people of working-age who are on a low income.
(ii) Is a wait for Universal Credit a contributing factor to the client's need for emergency food aid? (*)
YesNo

(ii/a) Date of Universal Credit application (if known)

(iii) Are you receiving any advice and support for your situation from any of the following? (*)
Job CentreCitizens AdviceOtherI am not receiving advice or support

(iii/a) Details of Other (*)

(iii/b) Luton Foodbank has a funded partnership with Citizens Advice, so clients can get free advice and support to help relieve crisis.
Help and advice is available if the client is affected by homelessness or threat of homelessness, lack of recourse to public funds, violence/abuse, mental health crisis, benefits problems, priority debt with enforcement action imminent, has children in need (court / social services), or is an institutional leaver (care/forces/prison).
Would the client like help from a Citizens Advice representative? (*)
YesNo

5. ETHNICITY & DISABILITIES

(i) Ethnic group
WhiteMixedAsian or Asian BritishBlack or Black BritishChinese or other ethnic groupPrefer not to say

(ii) Disabilities
Does the client consider themself to have any disabilities?
YesNoPrefer not to say

Level Trust has created a limited number of learning packs for children who are currently off school. These wil be available week commencing 30/3/20. Please state requirements.
Age 4-6:
Age 7-11:
Age 12-16:

Please remind the client about safe conduct when attending distribution.
Only ONE person to attend. (Bring a suitcase or trolley if you don't have transport.)
Remain at least 2 metres from volunteers and other clients.
Wash hands well and regularly.

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