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Food Bank (partner referral) form
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Full name
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Date of birth
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YYYY
Address (inc post code)
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Mobile Number
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Gender
Female
Male
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Ethnicity
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Asian
Black African
Arab
Black Caribbean
White
Other
Faith
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Muslim
Christian
Jew
Hindu
Other
How many people live in your household
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Allergies/Dietary requirements
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Reason for support
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Benefits recently stopped
Low income
Redundancy
Mental Health
Disability
Domestic Abuse
Homeless
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