Referral form

Coming soon...

Stripey Stork Referral Form

Page 1

Welcome to Stripey Stork's referral form for families in need.

Please complete the form - there are four pages - adding a new section for each household member. You can add the items needed for each individual, adding up to a maximum of thirty different items.

If you would like to refer more than one family, please ensure you complete this form and click Submit before completing a new form.

If you have any queries, please contact [email protected]

And for further information about how we use your data, please click here.

Do you agree to our referral policy? (located here)

Referral policy - please read

If you are unable to agree to our referral policy we cannot process your referral further. Please contact [email protected] for further information

Your Details

Please select your type of organisation and then the name of the organisation. If you are unable to find your organisation name, please select NOT LISTED and complete the following questions.

Type of organisation

Organisation

Organisation name

Team

Your first name

Your surname

Your email address

Your mobile number

Postcode of your work address

We collect geographical information to derive the areas where our service is most needed and used. We store this data securely, and take measures to prevent it from being disclosed to third parties. The data is collected via our referral partners, and is only used in aggregated form to assess the impact of our work. The system we are using to manage referrals data is Salesforce, the world’s #1 cloud-based CRM system. It has robust data security measures in place. You can find out more about how Salesforce protects your data here (https://trust.salesforce.com/en/).

Page 2

Please provide information about the household and individual family members. Click on add another household member to add more.

Household info

How many adults in the household

How many children under the age of 16 in the household

Include children due to join your household, as well as unborn children

Postcode of primary carer

Ethnicity of primary carer

Are the primary carers in work?

Reason for referral (select all applicable):

To select more than one, hold down control (ctrl) (PC) or command (Mac) and select multiple reasons

Other Reason for Referral:

Estimated due date of baby (if mother is pregnant):

Please complete for all members of the household under the age of 16

Gender

Age

Page 3

Please complete a request for each item, click on Request another item to add further items.

Items - complete for each item

Page 4

Last few bits and pieces

Please choose the day of the week you would like to collect

Preferred collection date (please allow a minimum of 48hrs)

Please only choose a day Monday to Thursday. Stripey Stork is not open Friday to Sunday.

Time slot

Please choose the best time slot for collection

Please add any other notes, requests or comments about this request

And lastly, would you like to receive email updates on our campaigns (eg. Santa
Stork) and opening times?

If you have another referral for a different household to make, make sure you submit this form first, then start the process again refreshing your screen.

Contact Information

Help with using the referral form

Stripey Stork Referrals Instructions can be found here

Stripey Stork Referral Policy can be found here

Referral form

Coming soon...

Stripey Stork Referral Form

Page 1

Page 2

Please provide information about the household and individual family members. Click on add another household member to add more.

Page 3

Please complete a request for each item, click on Request another item to add further items.

Page 4

Help with using the referral form

Join the Stripey Stork mailing list

Stripey Stork - Family Support. Recycled

Site Links

Our Policies

Other Baby Banks

Referral form

Coming soon...

Stripey Stork Referral Form

Page 1

Page 2Please provide information about the household and individual family members. Click on add another household member to add more.

Page 3Please complete a request for each item, click on Request another item to add further items.

Page 4

Help with using the referral form

Join the Stripey Stork mailing list

Stripey Stork - Family Support. Recycled

Site Links

Our Policies

Other Baby Banks

Page 2

Please provide information about the household and individual family members. Click on add another household member to add more.

Page 3

Please complete a request for each item, click on Request another item to add further items.