Please select your groups primary activity Children & Families Centre Soup Kitchen Place of Worship Supported Housing Community Centre Luncheon Club Community Cafe Training Centre Day Centre Residential Rehabilitation Service Drop-in Service Medical Facility Food bank Addiction Support Hostel Advice / Resource Centre Hospice / Care Home Refugee Centre Out of School / Youth Centre Prison School / Breakfast Club / After School Club Other: ___________________________ Secondary Activity (from above list) Tertiary Activity (from above list) Beneficiary group details Gender Percentage Male Female None of the above Prefer not to say Age Percentage Children (Under-11) Children (11-15) Young adults (16-25) Adults (26-64) Elderly (over 65) Prefer not to say Ethnicity Percentage Asian Black White Mixed Ethnicity Other Prefer not to say Please select primary service Social / Befriending Life Skills Training Recreational / Leisure Child Care Referral / Signposting Accommodation Benefits / Financial Advice Employment Support Training Mental Health Support Drug and Alcohol Advice Education Housing Advice Food Parcels Complementary Health Breakfasts Medical Meals Social Work Services Other: ___________________ Secondary Service (from above list)
Please select your groups primary activity Children & Families Centre Place of Worship Community Centre Community Cafe Day Centre Drop-in Service Food bank Hostel Hospice / Care Home Out of School / Youth Centre School / Breakfast Club / After School Club Soup Kitchen Supported Housing Luncheon Club Training Centre Residential Rehabilitation Service Medical Facility Addiction Support Advice / Resource Centre Refugee Centre Prison Other: ___________________________ Secondary Activity (from above list) Tertiary Activity (from above list) Beneficiary group details Gender Percentage Male Female None of the above Prefer not to say Age Percentage Children (Under-11) Children (11-15) Young adults (16-25) Adults (26-64) Elderly (over 65) Prefer not to say Ethnicity Percentage Asian Black White Mixed Ethnicity Other Prefer not to say Please select primary service Social / Befriending Recreational / Leisure Referral / Signposting Benefits / Financial Advice Training Drug and Alcohol Advice Housing Advice Complementary Health Medical Social Work Services Life Skills Training Child Care Accommodation Employment Support Mental Health Support Education Food Parcels Breakfasts Meals Other: ___________________ Secondary Service (from above list)