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

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.









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


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

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/).



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


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


Page 3

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

Items - complete for each item


NB
Pressure-mounted safety gates should NOT be used at the top of the stairs
NB
For school uniforms, please give details in the Comments box on the next screen
NB
As you have selected nappies or pull-ups, two packs of wipes will be added to your order
NB
Subject to availability our Clothes Packs include as standard:  a winter coat, lightweight coat, hat, jumpers, trousers, long and short sleeved t-shirts, shorts / skirts / dresses, pyjamas, new underwear and socks. When available they may contain extras such as sports clothing, dressing gowns and swimwear
NB
Subject to availability our Newborn Pack will include: baby clothing (newborn and 0-3 months), a baby bath, Moses basket and stand, sheets and blankets, sleeping bags, a change mat, towels, bibs, muslins, nappies (size 1 or 2) and wipes, a filled hospital/change bag, toiletries, and toys





Page 4

Last few bits and pieces


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

Please choose the best time slot for collection


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.

Help with using the referral form

Stripey Stork Referrals Instructions can be found here

Stripey Stork Referral Policy can be found here