Your Full Name *

First Name

Last Name

Full Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please Select The Number Of Indiviuals Requiring Assistance In This Family *

Food Parcel for 1 Adult

Food Parcel for 2 Adults

Food Parcel for a Family of 3

Food Parcel for a Family of 4

Food Parcel for a Family of 5

Food Parcel for a Family of 6+

If For A Family, Please Select The Applicable Option

Children aged 0-1

Children aged 2-5

Children aged 6-12

Children aged 13-18

By clicking "Submit" you are agreeing with the following: *

You have asked the individual's permission to share their information with Al Miftah Registered Charity In England & Wales 1191922

They have understood that the information being shared will only be used to best facilitate them using Al Miftah's Food Parcel Assistance. Information will only be shared with relevant staff and Food Parcel volunteers who will treat any information shared with respect and confidentiality.

Al Miftah will store the information for future reference and for anonymous statistics to monitor and better improve the resources we provide