Register for a box

Please fill the form below to register for a box

Step 1 - Referrer’s details

Please add your details below

1. Referrer’s contact info*

Step 2 - Add persons

Please add your client details below. You can add more than one persons

Person 1

2. Is the referred person aware of this referral & have they given consent?*

3. Is the referred person able to collect their hamper themselves on distribution date? (Please note those who can not collect, will need to arrange for someone to do so on their behalf.)*

4. Person being referred contact info*

5 . Are they in receipt of benefits*

6. Household demographic*

7. Ethnicity*

5. Age*

6. What time is most suitable for you to collect on Saturday 23rd of December (multiple selections allowed)*

Person 2

2. Is the referred person aware of this referral & have they given consent?*

3. Is the referred person able to collect their hamper themselves on distribution date? (Please note those who can not collect, will need to arrange for someone to do so on their behalf.)*

4. Person being referred contact info*

5 . Are they in receipt of benefits*

6. Household demographic*

7. Ethnicity*

5. Age*

6. What time is most suitable for you to collect on Saturday 23rd of December (multiple selections allowed)*

Person 3

2. Is the referred person aware of this referral & have they given consent?*

3. Is the referred person able to collect their hamper themselves on distribution date? (Please note those who can not collect, will need to arrange for someone to do so on their behalf.)*

4. Person being referred contact info*

5 . Are they in receipt of benefits*

6. Household demographic*

7. Ethnicity*

5. Age*

6. What time is most suitable for you to collect on Saturday 23rd of December (multiple selections allowed)*

Person 4

2. Is the referred person aware of this referral & have they given consent?*

3. Is the referred person able to collect their hamper themselves on distribution date? (Please note those who can not collect, will need to arrange for someone to do so on their behalf.)*

4. Person being referred contact info*

5 . Are they in receipt of benefits*

6. Household demographic*

7. Ethnicity*

5. Age*

6. What time is most suitable for you to collect on Saturday 23rd of December (multiple selections allowed)*

Person 5

2. Is the referred person aware of this referral & have they given consent?*

3. Is the referred person able to collect their hamper themselves on distribution date? (Please note those who can not collect, will need to arrange for someone to do so on their behalf.)*

4. Person being referred contact info*

5 . Are they in receipt of benefits*

6. Household demographic*

7. Ethnicity*

5. Age*

6. What time is most suitable for you to collect on Saturday 23rd of December (multiple selections allowed)*

Person 6

2. Is the referred person aware of this referral & have they given consent?*

3. Is the referred person able to collect their hamper themselves on distribution date? (Please note those who can not collect, will need to arrange for someone to do so on their behalf.)*

4. Person being referred contact info*

5 . Are they in receipt of benefits*

6. Household demographic*

7. Ethnicity*

5. Age*

6. What time is most suitable for you to collect on Saturday 23rd of December (multiple selections allowed)*

Person 7

2. Is the referred person aware of this referral & have they given consent?*

3. Is the referred person able to collect their hamper themselves on distribution date? (Please note those who can not collect, will need to arrange for someone to do so on their behalf.)*

4. Person being referred contact info*

5 . Are they in receipt of benefits*

6. Household demographic*

7. Ethnicity*

5. Age*

6. What time is most suitable for you to collect on Saturday 23rd of December (multiple selections allowed)*

Person 8

2. Is the referred person aware of this referral & have they given consent?*

3. Is the referred person able to collect their hamper themselves on distribution date? (Please note those who can not collect, will need to arrange for someone to do so on their behalf.)*

4. Person being referred contact info*

5 . Are they in receipt of benefits*

6. Household demographic*

7. Ethnicity*

5. Age*

6. What time is most suitable for you to collect on Saturday 23rd of December (multiple selections allowed)*

Person 9

2. Is the referred person aware of this referral & have they given consent?*

3. Is the referred person able to collect their hamper themselves on distribution date? (Please note those who can not collect, will need to arrange for someone to do so on their behalf.)*

4. Person being referred contact info*

5 . Are they in receipt of benefits*

6. Household demographic*

7. Ethnicity*

5. Age*

6. What time is most suitable for you to collect on Saturday 23rd of December (multiple selections allowed)*

Person 10

2. Is the referred person aware of this referral & have they given consent?*

3. Is the referred person able to collect their hamper themselves on distribution date? (Please note those who can not collect, will need to arrange for someone to do so on their behalf.)*

4. Person being referred contact info*

5 . Are they in receipt of benefits*

6. Household demographic*

7. Ethnicity*

5. Age*

6. What time is most suitable for you to collect on Saturday 23rd of December (multiple selections allowed)*