FFU Scotland CIC Nomination for Compassion Hampers

FFU Scotland CIC NOMINATION FORM

Compassion Hamper Appeal for those living with Fibromyalgia who have had further Trauma, Significant increase in Mental Health and loss this year.

CLOSING DATE FOR APPLICATIONS FRIDAY 10TH DEC 2021 5PM
This is to allow hampers to be ready for the delivery schedule commencing 17th December onwards

Please note that this is NOT a self referral . This is for you to nominate someone that would benefit from knowing they are not alone after a difficult year. REFERRALS CAN BE BY A PROFESSIONAL OR THE PERSONS CARE SUPPORT/FAMILY.

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SECTION A WHO ARE YOU NOMINATING

Full Name:

Address Line 1:

Address Line 2:

Post Code:

Phone:

Email:

SECTION B YOUR DETAILS AS THE NOMINATOR/REFERRER

Name of Nominee ( relationship to person or job title if applicable)

Name of organisation referring if applicable

Contact number of organisation if applicable

Name of organisation referring if applicable

Name of person to receive:

Address Line 1:

Address Line 2:

Post Code:

Phone:

Email:

Age range of nominated person

18-29

30-39

40-49

50-59

60+

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SECTION C REASON FOR REQUEST

Please advise who has fibromyalgia and year of diagnosis (ESSENTIAL)

Please clearly state the reason you are requesting to nominate this person for a compassion hamper to receive a compassion wellbeing hamper.

Please provide as much info as you can to help us help them as we may also be able to signpost or support with other services to help them at this time and in the future management of their syndrome,

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Further information (please complete)

This information helps us to ensure your safety and the safety of volunteers

Do you know if the person has been contacted by track and trace and advised to isolate for 14 days?

YES

NO

UNSURE

Do you know if the person or someone in their household have COVID symptoms and self isolating for precautions

YES

NO

UNSURE

Do you know if the person has a current positive PCR test

YES

NO

UNSURE

This service is FREE.

If when you can afford to help this would be greatly appreciated as this will help us to continue to help others in the same situation.

Payments can be made via PayPal : ffu-scotland@hotmail.com

By doing a balance transfer to our bank details – 82-67-32 10022260 reference – your name

CLICK TO DONATE

CLICK DONATE VIA PAYPAL

What happens next?

Once we receive your nomination form, we will confirm receipt in an email to the person you nominated as well as yourself.

We anticipate all deliveries of hampers to be between 17th and 23rd December 2021.

We will further contact your nominated person with the date we are delivering to their area, where possible for deliveries we will try and group delivery areas together. Some hampers may be delivered via a courier if in further more difficult to access areas of Scotland for our volunteer team.

Please continue to follow the current advice being provided by the Scottish Government and NHS Scotland. Their advice pages are as follows:

NHS Inform Link
Scottish Government Link

Scottish Emergency hotline number for vulnerable people which is other than those shielding such as over 70, living with disabilities, mental health, pregnant etc 0800 111 4000

If your nominated person are NOT already a member of FFU Scotland CIC or you have any service user(s) living with fibromyalgia please send them the links and information so they may request to join our main social media closed support page
CLICK HERE

We can also be followed on our Public Facebook page

https://www.facebook.com/fibroscotland

Thank you so much and if FFU Scotland CIC can help in other ways please email us E-MAIL US

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Under the GDPR (2018) your data will only be used for the purpose of the FFU SCOTLAND CIC Christmas Hamper Campaign unless you have marked the GDPR consent box to allow us to hold your information safely in order that we can update about future work and services provided by FFU Scotland CIC.
We will never share your information with a third party.

Only the persons address and first name and no other detail will be passed to the volunteer who is delivering. These details are then passed back to our office for destroying

I CONFIRM I HAVE READ & UNDERSTAND THE ABOVE MESSAGE

I CONFIRM I WOULD LIKE TO BE ADDED TO FFU SCOTLAND CIC GDPR DATA BASE AND BE KEPT UP TO DATE ABOUT SUPPORTS / SERVICES / EVENTS AVAILABLE FROM THE ORGANISATION.

I CONFIRM THAT I DO NOT WISH TO BE ADDED TO FFU SCOTLAND CIC GDPR DATA BASE AND BE KEPT UP TO DATE ABOUT SUPPORTS/ SERVICES/ EVENTS FROM THE ORGANISATION

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Please tick the following box to confirm that you agree that the persons compassion hamper will be left on their doorstep for collection and the volunteer will wait until it is collected by the person.

This is so our volunteer is not breaching the social distancing guidance recommended by the government – this is not only for the persons safety but that of our volunteer.

I AGREE

TICK TO CONFIRM YOU HAVE READ AND AGREE

DATE ALLOCATED

FFU SCOTLAND CIC ONLY

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Comments:

This is required

FFU Scotland CIC Nomination for Compassion Hampers

SECTION A WHO ARE YOU NOMINATING

SECTION B YOUR DETAILS AS THE NOMINATOR/REFERRER

Age range of nominated person

Further information (please complete) This information helps us to ensure your safety and the safety of volunteers

DATE ALLOCATEDFFU SCOTLAND CIC ONLY

Further information (please complete)

This information helps us to ensure your safety and the safety of volunteers

DATE ALLOCATED

FFU SCOTLAND CIC ONLY