Questions marked with an asterisk (*) are mandatory.

1. AGENCY & REFERRER DETAILS

(i) Referrer's name (*)

(ii) Referrer's organisation (*)
Luton Citizens AdviceSalvation ArmyNOAH EnterpriseNational Probation Service / BeNCH CRCPenrose SynergyBritish Red CrossKeystage HousingDiscover IslamYMCA BedfordshireLuton Community HousingLuton FoodbankELTFWomen's Aid in LutonMary Seacole Housing AssociationEarly Help Team Children's ServicesFlying Start CentralStepping StonesFlying StartChildren's Centre WestLangley House TrustCSS - Luton Community UnitChildren's Services - Luton Borough CouncilLuton RightDallow Primary SchoolFlying Start Luton SouthStronger Familes (LBC)Flying Start Children's Centre NorthCSS - Luton Health Visiting ServicesMears Housing ManagementTerrence Higgins TrustELFTLuton All Women's CentreRothesay NurseryTennyson Road SchoolPutteridge Primary School

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

(iv) Email voucher should be sent to (*)

(iv) Referrer's email if different from above (*)

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

6. PRIVACY NOTICE

Luton Foodbank (LFB) will store the client's personal information securely and process it in accordance with the General Data Protection Regulation 2016. The lawful basis for holding this information is called ‘legitimate interest’. We will hold their records for 6 years. We will never pass their information to an external individual or organisation without asking their consent first, unless we have reason to believe that our service may being abused. They have a right to:

• see the information we hold on you.request that any errors in your information are corrected.

• request that their information is erased from Luton Foodbank’s records. (If there is no good reason for LFB to hold your information, LFB would agree to their request to remove their information. However, there will be a continuing good reason to hold the information to help us ensure that the service is not being abused)

• complain about any data issues, using the LFB Complaints Procedure by calling 01582 725838
  or email info@lutonfoodbank.org.uk

LFB will agree to their requests about their data as soon as practically possible and not later than 1 month from the date of request.

I have made the client aware of the privacy notice.

7. FORM SUBMISSION

When you submit this form, a unique password will be sent to your email address. You will need this password to unlock the PDF voucher that is generated. Please check the email address you have given above is correct. Thank you.