Applying for foodbank Support

Name*

Address*

Phone*

Email*

Gender (identify as)*

Male

Female

Prefer not to answer

Ethnicity

Maori

Pacific Islander

European

Others

Date of Birth*

Where did you hear about our food bank?*

Facebook

Neighbourhood

YouTube

News paper

Someone told me about it.

Web search

Flyer/brochure

Other

Others

Brief description of your situation*

Food pack type*

Vegetarian

Vegan

Gluten free

FODMAP

Others

Family Status*

Single Parent

Couple (with children)

Couple (no children)

Extended family

Individual

Prefer not to answer

Please list other member of the household. (Full name, Date of birth, relationship to you)*

Current living situation*

Transitional

Evacuee

Own home

Flatting

renting

HNZ

Holiday park

Living with family or friends

Sharing room/couch surfing

Homeless - living in car

Homeless - other

Others

Have you requested a food grant from WINZ or MSD?*

Yes

If you have one, your Work and income client Number:

Main source of income*

Benefit

Wages

No income sources

Others

The total gross income (before taxes) of members of the household

Are any of these an issue for you at present (tick as many as apply)

power bill

hospital app.

Vet bills

Rent

Car

Phone

Doctor

Dentist

Moving

Baby milk/nappies

School fees

shoes/uniform

Extra people staying

Stationery

Household items

Are there other needs or comments

Static Content

Disclaimer

The food products and grocery items contained in this food parcel have been sourced form various food outlets & manufacturers and may be SECONDS, DAMAGED or indicate PAST-USE-BY-DATE, which may leave some products with a minimum of safe life.
Every attempt has been made to insure this parcel arrives to you in a safe and usable condition. but final assessment by you, the recipients before consumption is essential.
I therefore accept that the items contained in this parcel have been donated and intended solely for the use of the recipient/s and must not be sold or traded.
I also agree not to hold liable in any way whatsoever any donor who has contributed to the provision of this parcel including the Mountain Meadows Charitable Trust, food outlets & manufactures.
Your acceptance of this DISCLAIMER is a pre-condition to your acceptance of this food parcel and by way of ticking YES below it is taken as acceptance by you of these conditions.

Privacy waiver and confidentiality clause
The Mountain Meadows Charitable Trust collects the above information for the following reasons:

To help us provide a quality service and the assist you better in the future
To provide statistical data (we will ensure you cannot be identified)
To allow for possible information sharing with other food banks and support organisations in the area.

Do you Accepted this Disclaimer and Privacy Waiver:*

Yes

Date you accepted or rejected this Disclaimer and Privacy Waiver*

NOTE:

If you can not accepted this Disclaimer and Privacy waiver - please contact us.

Applying for Support

If you can not accepted this Disclaimer and Privacy waiver - please contact us.