BASIC FOOD BOX If you are interested in receiving a basic food box, please take a few minutes to pre-register using this form. Unique IDThis is not an actual order for a food box but the information you provide will greatly help our volunteer coordinators in planning, sourcing and delivering this assistance efficiently. The contents of the basic food box will depend on the availability of products on the day. This is not an individual shopping service.Who is it for?*Are you registering for your own household or on behalf of someone who is unable to register themselves?For myselfFor someone elseYour NamePlease enter your own name here. First Name Last Name Household Contact Details Please enter the details of the person you are registering on behalf Household Contact Details Please enter your details below Household Contact* First Name Last Name If the person you are registering for does not have access to email, please enter your own email address here.Contact Email* Enter Email Confirm Email Household Address* Street Address Town Postcode Household Phone Number* Household requirementsPlease indicate the relevant information for your household's requirementsAdults*How many adults are there in your household?1234ChildrenHow many children are there in your household?01234 Vegetarian*Is anyone in your household vegetarian?NoYesNumberHow many people are vegetarian? Allergies*Does anyone in your household have any food allergies?NoYesNumberHow many people have allergies?Allergy detailsPlease select any food allergies Wheat allergy Lactose intolerant Nut allergy Fish or shellfish allergy Other Other AllergyPlease indicate briefly the nature of the food allergyPriorityPlease complete the following section to help ensure that food boxes are delivered to the most vulnerable households within the community first.Shielding*Have you been advised by the NHS to shield yourself at home?NoYes Caring*Are you caring for someone who is shielding or someone who is clinically extremely vulnerable to coronavirus?NoYes Urgency*When you do anticipate requiring delivery of a food box?As soon as possibleIn a weekIn a fortnightIn a monthThank you for taking the time to pre-register. We'll get in touch with you when the basic food boxes become available for delivery.