Dinner Service self-referral form

Thank you for your interest in the Glass Door Dinner Service, we just need to ask a little bit of information about you. We are asking these questions so that we can safely administer you a place in one of our dinner services and so that we can report on the need of our service. All information will be kept in line with Glass Door’s Privacy Policy (see link in footer of website).

The Glass Door Dinner Service operates in four boroughs: Kensington & Chelsea, Hammersmith & Fulham, Wandsworth, and Richmond. Which of these would be suitable for you? (feel free to tick multiple options) (required)

Kensington & ChelseaHammersmith & FulhamWandsworthRichmond

(Online referrals require a mobile number for SMS confirmation. If you do not have a mobile, please speak to staff or volunteers at one of our daytime drop-in services - https://www.glassdoor.org.uk/daytimesupport.)

Do you give consent for us to share your number with NHS Test & Trace if we need to? (this question is optional and will not affect your application)

YesNo

Are you currently rough sleeping? (This question will not affect your application, the Glass Door Dinner Service welcomes anyone who will benefit from it. The data is for our own internal purposes and we will not share it with external parties)

YesNoPrefer not to say

Which of the following best describes your dietary requirements? (required)

No dietary requirementsVegetarianHalalKosherPescatarianVegan

If none of the above accurately describes your dietary requirements (e.g. if you eat chicken but not red meat) please give details here

Please note that if you are unable to attend on a night we are expecting you or wish to swap/attend extra nights, please call us. Unexpected absence may lead to us giving your place to someone else.

Which day(s) would you like to attend the Glass Door Dinner Service? (please tick all that apply) (required)

Full weekMondayTuesdayWednesdayThursdayFridaySaturdaySunday