Community Supermarket Referral Form

Applicant Details

First Name

Last Name

Birth Date

Street Address

City

Postcode

Phone Number

Email Address (if applicable)

Preferred Contact Method

Phone

Email

SMS

State/Province

Household Information

Number of Adults in Household

Number of Children in Household (under 18)

Any Vulnerable Individuals in the Household?

Yes

No

If Yes, please specify

(e.g., disability, long-term illness, caring responsibilities)

Eligibility Criteria

Please select all that apply

Managing on a low income or dealing with financial pressure

Currently out of work or working fewer hours than usual

Receiving Universal Credit or other financial support

Going through a tough time (e.g., housing issues, bereavement, domestic challenges, or seeking asylum)

Living with a health condition that affects your income or access to food

Caring for someone and finding it hard to make ends meet

Something else affecting your situation? Let us know

Other (please specify):

Support Needs

Has the applicant accessed foodbanks or other support services before?

Yes

No

Does the applicant need additional support?

(e.g., budgeting advice, employment support, mental health services)

Yes

No

If Yes, please provide details:

Are there any dietary or cultural food requirements?

Yes

No

If Yes, please specify

Demographic Information

Consent & Declaration

Applicant Consent

I confirm that the information provided is accurate to the best of my knowledge. I consent to my details being shared with the Community Supermarket for the purpose of assessing eligibility and providing support.

Yes

Referrer Declaration

I confirm that the individual/household has given consent for this referral.

Yes