Consent Form

Explain to the guest that since they are claiming the requirement of free food portions we need to get an assessment by a community professional to confirm such need. It is important to note that SHOULD A GUEST WHO CLAIMS TO BE UNABLE TO GIVE A DONATION FOR A MEAL NOT SIGN THIS CONSENT FORM IT WILL BE UNDERSTOOD THAT S/HE IS NOT INTERESTED TO HAVE A MEAL AT IR-REFETTORJU TAL-KĊINA TA MARTA.

Consent Form

Name/Isem(Required)

Name/Isem Surname/Kunjom

Date of Birth(Required)

Passport/ID Number(Required)

Address

Parish/Locality(Required)

Landline

Mobile(Required)

Do you have a Social Worker?

Yes

If Yes Please Give us your Social Workers/Professional Name

Agency of your Social Worker/Professional

Phone/Mobile of Social worker/Professional

I, the undersigned, hereby provide my consent to LOOP Djakonija Parroċċi to share my details to professionals/agencies who can help me according to my needs.(Required)

Please read and indicate your consent to the sharing of your information for your care and potential referrals:

Name of Person filling in this form

First Last