Hidden fields

ReferralID

PersonID

Referrer

ReferralUniqueLink

Filled in by Family

The form will automatically be displayed in English. To change what language the form questions show in, please select an option from the dropdown.

You've been referred to Little Village but we have been asked to get more detail from you about what you require as your referrer was unsure. Please press next and fill in details

Refer a family to Little Village

Thank you for your interest in referring a family to Little Village. We provide clothes and equipment for babies and children up to the age of 5. Please make sure you explain to the family how Little Village works before making the referral. Unless there is information we need to clarify, we will not contact the family directly before delivering their bundle. Please make sure the information on the form is accurate.

Which borough does the family live in?

BarnetBrentBromleyCamdenCity of LondonCity of WestminsterCroydonHackneyHammersmith and FulhamHaringeyIslingtonLambethLewishamMertonRichmond upon ThamesRoyal Borough of GreenwichRoyal Borough of Kensington and ChelseaRoyal Borough of Kingston upon ThamesSouthwarkSuttonTower HamletsWandsworthNone of the aboveWe are only able to provide clothing and kit for families who live in these boroughs.

Unfortunately, we can't support the family at this time because they live outside our core boroughs. You can find links to other baby banks and other resources which may be useful on our website

https://littlevillagehq.org/family-support-resources/

Your Details

First Name

Last Name

Your Role

What other role do you hold?

Which organisation do you work for?

Tell us a bit about where you work. Is it:

Please describe what 'other' type of organisation you work for

Which borough does this organisation usually work in? If you work in multiple boroughs, please use the head office location

First Name

Last Name

What's the best email address for us to contact you on if we have any questions?

What's the best number to contact you on if we have any questions?

Please enter in numbers with no spaces

Family Details

Thanks for providing all your information. Now we need some details about the person you're referring.

First Name

Last Name

Please tell us their date of birth

Have you referred family before?

Street Address (including block name if relevant)

PLEASE ENSURE ADDRESS IS COMPLETE AS WE WILL NOT BE ABLE TO DELIVER OTHERWISE.

What's their full postcode (e.g. SWXX XXX)?

What’s their phone number?

PLEASE ENTER NUMBERS ONLY - DO NOT LEAVE ANY SPACES

Please reconfirm their phone number

We cannot deliver to families without an accurate phone number.

Do you have their email address?

YesNo

What's their email address?

Referral Details

What are the main reasons for your referral?

Affected by substance misuse Benefits Sanctioned Dealing with domestic violence Debt Difficulties with Universal Credit Disabled Disabled child Economic hardship due to Covid-19 Homeless Low or uncertain wage No access to public funds Seeking asylum Single parent Temporary accommodation Victim of trafficking / Modern slavery Young parent (under 25) Other

Please describe more detail here

Please tell us how many people live in same household under categories below

0-5 years including unborn child(ren)

6-11 years

12-17 years

Total Children 0-17

Men (18 years+ including parent/carer)

Women (18 years+ including parent/carer)

Please check over the address and contact details to make sure this is correct.

Street Address (including block name if relevant)

What's your full postcode (e.g. SWXX XXX)?

What’s your phone number?

(Please note, we cannot deliver items to you without a phone number. Please ensure this number is up to date and all digits are included - thanks!)

Additional Family Information

What is the first language spoken at home?

What is the ethnic background of your/the family?

Please choose

Ethnicity

What is the religion or faith of your/the family?

Please describe more detail here

Is someone in the household in employment?

Is this recent and as a result of Coronavirus-related layoffs?

This next section is about the items the family needs. We strongly recommend that referrers complete this information in discussion with the family and on their behalf. If preferred, we can send the family an email so they can complete the items needed. However, this may cause a delay in processing their referral.

Are you selecting the items needed on behalf of the family?

YesNo

You have asked us to send the family an email to complete the rest of the referral. Please make sure you have supplied the family's email address on page 3 of this form.

Child Details

Please complete this section for one child. If there are other children (including twins or triplets) up to the age of 5 who need items, please select “Add another child” below. Please enter the child’s actual age - you will be able to indicate below if the children are wearing clothes of a different age group.

Sex

Age

Age and Sex Hidden

Items needed

Most of the items we offer are donated and so we can only gift out what we have received from the public. Because of this, we may not have all items available and during busy periods may need to limit what we can offer.

Please make sure the family are aware that the majority of the items we send will be second hand. We make sure they are in great condition and quality, clean and fit for use.

Please let us know what items are needed for this child by checking the relevant boxes and then selecting from the list below. If the child doesn’t need this item, please don’t check the box.

If there are other children (including twins or triplets) up to the age of 5 who need items, please select “Add another child” at the bottom of the page after you have entered the items for the first child.

Items needed

Please be aware that the majority of the items we send will be second hand. We make sure they are in great condition and quality, clean and fit for use.

Please let us know what items are needed for this child by checking the relevant boxes and then selecting from the list below. If the child doesn’t need this item, please don’t check the box.

Does the child need clothes?

Nappies (with wipes). Which size would you like?

Shoes

Which size would you like?

Clothing

Gender

What size would you like?

Clothing Hidden

Coat and accessories? (Suitable for season?)

Winter CoatCoat (non seasonal)Accessories

Is there anything specific that we need to know about clothing?

Clothing Summary Hidden

Toys/Books

ToysBooks

Is there anything particular the child likes to play with or read? We can’t promise it will be available, but we will try to select suitable toys and books for the child’s age.

Toys Books Summary Hidden

Sleeping equipment (all beds come with new mattress)

What is your preferred choice?

What is your second choice if your preferred choice is not available?

Are you/the family happy to accept a mattress only if no bed is available?

Mattress Size

Bed and Mattress (Hidden)

Sleeping accessories

Moses basket sheetsCrib sheetsCot sheetsCotbed / toddler bed sheetsSwaddlesSleeping bags - 0-6 monthsSleeping bags - 6-18 monthsSleeping bags - 18 - 36 monthsMonitorDummiesTeethersBlanketsBedguardToddler duvet cover and pillow caseToddler duvet and pillow

Sleeping equipment Hidden

Bed Summary (Hidden)

Travel equipment

Buggy from birthBuggy (suitable for 6m-toddler)StrollerDouble buggyTriple buggyFootmuffBuggy boardScooterSling

Travel Summary Hidden

Bathing/changing equipment

What kind of bathing and changing equipment do you need?

PottyChanging matChanging bagBaby bathBath supportTowelsToddler toilet seat

As you have chosen 'changing mat' and 'changing bag', we will send you only one of these items depending on availability

Bathing Summary Hidden

Feeding equipment

What kind of feeding equipment do you need?

SteriliserSet of bottles and new teatsBottle warmerBreastfeeding pillowBreastfeeding cover upBreast pumpBreast padsBibsMuslinsHigh chairTravel high chairPlates and bowlsCutleryWeaning pots and storageCups / sippy cups

Do you have a microwave?

We’ll send a microwave steriliser if we can

As you have chosen 'Hair Chair' and 'Travel High Chair', we will send you only one of these items depending on availability

Feeding Summary Hidden

Child Summary (Hidden)

What is the due date of the unborn child/twin listed above?

Are any of the children part of multiple births (twins/triplets etc)?

Have you entered in all children part of this multiple birth?

Is there any other information that we need to complete this referral, including delivery instructions and access to the property? 

Nearly finished!

Thank you very much for making this referral to Little Village. We will pack the family’s items as soon as we can and confirm the delivery date with them directly. We aim to respond within 4-6 weeks.

Thank you very much for making this referral to Little Village. We will email the family a form to choose the items they need. We will aim to complete their referral within 4-6 weeks.

Please agree to these statements so that we can start working on your bundle.

Please ensure that you have explained these points to your family and can sign on their behalf where relevant. This question is required.*

1. I have explained to the client I am referring, and they have understood that most of the items supplied have been donated to Little Village by the public and accepted in good faith. Little Village cannot guarantee the reliability and safety of any of the items and we strongly recommend that they check and clean the items thoroughly before use.

2. I confirm that I have complied with the GDPR in my handling of the information provided on this form.

3. I confirm that I have my client’s consent to share the information provided on this form for the purposes of accessing Little Village’s services.

4. I have informed my client that their name, address and contact number will be shared with a third party delivery company or volunteer to enable delivery of the items requested.

5. I understand, and have explained to the family that I have referred that the information collected about me and the family I have referred on this form will be stored by Little Village in accordance with its policies and may be used for impact evaluation. A copy of our data protection policy is available on our website.

I consent

Please confirm if you are happy for us to keep you informed of Little Village’s news, fundraising efforts or about taking part in user surveys and events, by:

Post

Phone

SMS

Thank you very much for letting us know about the items you’d like from Little Village. We will pack your items as soon as we can and confirm the delivery date with you directly. We will aim to complete your referral within 4-6 weeks.

Please agree to these statements so that we can start working on your bundle.

1. I have understand that most of the items supplied have been donated to Little Village by the public and accepted in good faith. Little Village cannot guarantee the reliability and safety of any of the items and we strongly recommend that they check and clean the items thoroughly before use.

2. I consent to share the information provided on this form for the purposes of accessing Little Village’s services.

3. I consent to my name, address and contact number will be shared with a third party delivery company or volunteer to enable delivery of the items requested.

4. I understand that the information collected about me and my family I have referred on this form will be stored by Little Village in accordance with its policies and may be used for impact evaluation. A copy of our data protection policy is available on our website.

I consent

Please confirm if you are happy for us to keep you informed of Little Village’s news, fundraising efforts or about taking part in user surveys and events, by:

Post

Phone

SMS