Together for Short Lives
Call the Helpline 0808 8088 100

Food voucher referral form

Thanks to a new partnership we are now able to support families with a food voucher worth £100. These vouchers can only be redeemed in person at a store and referrals for a voucher must be made by a palliative care professional working with the family.

If you are working with a family caring for a child with a life-limiting or life-threatening condition who are struggling financially, please submit a referral on their behalf below.

Food voucher referral form

This information is required for Together for Short Lives to enable a food voucher to be issued

Your information

Parent/carer's information

A £100 M&S voucher will be emailed directly to the family. If the family do not have access to an email account, please add their address below and the voucher will be posted.
Parent address (only required if voucher must be posted)

Ethnicity data (for monitoring purposes only)

Professional declaration

I confirm that this family are known to the palliative care team(Required)
The family understand that the information collected on this form will be used for payment, audit and monitoring purposes in line with Together for Short Lives' Privacy Policy(Required)
I have checked the email and address and can verify it is correct(Required)
The family has been informed that Together for Short Lives will contact them regarding this gift(Required)