Beneficiary Application Form Section 1: Beneficiary Information Contact Number Number of Adults Number of Children: Age Group:—Please choose an option—16-2425-64Over 65 Ethnicity:—Please choose an option—WhiteBlack/African/Caribbean/Black BritishMixed Ethnic GroupAsian / Asian BritishChineseOther Ethnic Group Section 2: Service Requirements Support RequestedSelect those applicable—Please choose an option—Food ParcelFood Parcel DeliveryMealClothingGuidance & Signposting Delivery Reason—Please choose an option—Loss of TransportShort Term IllnessLong Term IllnessDisabilityElderlySafeguarding Referral?—Please choose an option—YesNo Referee Contact/Organisation: Referee Contact Number: Are you accessing other foodbank services?—Please choose an option—YesNo Section 3: Circumstances Nature of Crisis: (Select those applicable) —Please choose an option—Benefit ReductionBenefit DelaysAwaiting First Benefit PaymentDelayed WagesDomestic AbuseChange in relationship statusLoss of family / friend’s supportUnemployment / loss of jobLow IncomeChange in work hoursOther unexpected expenseRising cost of essentialsDebt (priority / non-priority)Refused Crisis LoanRough SleepingTemp AccommodationSofa SurfingNew Physical or Mental Health ConditionOngoing Physical or Mental Health ConditionChange to existing Physical or Mental Health ConditionChild Holiday MealsIncrease in Dependents Please tick here to confirm the information you have provided is correct to the best of your knowledge Your personal data is stored in compliance with Swale Community Care Projects GDPR Policy. Should you have any questions regarding your data please contact: contactus@swalecommunitycareproject.org Δ
