Make a referral to the Okehampton Food Bank

Name of your client *

First

Last

House name or number *

Street *

Post-code *

Mobile Number *

Email *

Number of Adults *

Number of Children *

Which Baby Milk?

Nappy Size

Any Dietary Requirements *

Allergies *

No known food allergies – Nobody in the household has any known food allergies.
Celery – Including celery stalks, leaves, seeds, celeriac and foods containing celery.
Cereals containing gluten – Including wheat, rye, barley, oats, spelt and foods made from these cereals, such as bread, pasta and biscuits.
Crustaceans – Including prawns, shrimp, crabs, lobster and foods containing shellfish of this type.
Eggs – Including egg whites, yolks, mayonnaise, cakes and other foods containing eggs.
Fish – Including salmon, tuna, cod, haddock, fish sauces and foods containing fish.
Lupin – Including lupin flour, lupin seeds and certain breads, pastries and baked products.
Milk – Including cow's milk, cheese, butter, yoghurt, cream and foods containing milk proteins.
Molluscs – Including mussels, oysters, scallops, squid, octopus and snails.
Mustard – Including mustard seeds, mustard powder, prepared mustard, dressings and sauces containing mustard.
Peanuts – Including peanuts, peanut butter, peanut flour and foods containing peanuts.
Sesame – Including sesame seeds, sesame oil, tahini, hummus containing tahini and foods containing sesame.
Soya (soybeans) – Including tofu, soya milk, edamame, soya flour and foods containing soya.
Sulphur dioxide and sulphites – Including sulphites used as preservatives in some dried fruits, drinks and processed foods.
Tree nuts – Including almonds, hazelnuts, walnuts, cashews, pecans, Brazil nuts, pistachios and macadamia nuts.
Other food allergy – Please provide below details of any food allergy not listed above.

Other Food Allergy

Primary reason for requiring Food Bank assistance *

Referral period *

Consent to contact food bank *

Referring Agency *

Name and Job Title of Referrer *

Contact Email of Referrer *

contact Information Post-code

Date *

Any Other Information